CNOs Remain Uncertain About DNP-Prepared Nurses

The number of RNs with doctorates of nursing practice is growing, but CNOs are still unclear about how DNP-prepared nurses can apply their skills and knowledge to benefit their organizations and the healthcare system.

In 2004, the American Association of Colleges of Nursing released a position statement recommending that "entry into practice" education for advanced practice nurses be raised from a master's degree to the doctoral level by 2015. Nurses with practice doctorates were rare at that time. According to AACN data, only three schools offered doctorate of nursing practice programs and there were only seven DNP graduates when the statement was released.

Though the 2015 goal hasn't been met—many schools still educate APRNs at the traditional master's level—the number of DNP programs and graduates has increased enormously over the past decade. In 2014 there were 269 schools with practice doctorate programs and 3,065 DNP graduates, while another 18,352 students were enrolled in DNP programs, reports the AACN.

As the number of DNP-prepared nurses continues to grow, many healthcare professionals are asking, "What are we supposed to do with them?"

Well, to be honest, the jury is still out. The authors of a 2014 AACN-sponsored study, "The DNP by 2015: A Study of the Institutional, Political, and Professional Issues that Facilitate or Impede Establishing a Post-Baccalaureate Doctor of Nursing Practice Program," concluded, "Many employers are unclear about the differences between master's-prepared and DNP-prepared APRNs and could benefit from information on outcomes connected to DNP practice as well as exemplars from practice settings that capitalize on the capabilities of DNPs."

Catherine Nichols, DNP, APRN, BC, nurse practitioner at the Barbara Ann Karmanos Cancer Institute's Walt Breast Center in Detroit, found similar results with her study, "Exploring Early and Future Use of DNP Prepared Nurses Within Healthcare Organizations."

Nichols surveyed CNOs at public and teaching hospitals in Michigan to assess their views on the use and effect of DNP-prepared nurses at their various facilities. She asked about DNP nurses' practice settings, employment of the four types of APRNs, chief nursing officers' satisfaction with DNP-prepared nurses' organizational impact, and their opinions on DNP nurses' influence on achieving patient-centered outcomes. Her study findings, which were published in the February 2014 issue of The Journal of Nursing Administration, were quite telling.

A lack of knowledge about DNPs

Nichols' study found gaps in CNOs' knowledge about the expectations, competencies, and projected outcomes of DNP-prepared nurses. After reading the study and speaking with Nichols, I'd characterize CNOs' views of the role of nurses with DNP degrees to be nebulous and narrow. They think hiring DNP-prepared nurses might be a good idea, but they're foggy on the specifics of how these nurses could contribute to their organizations. What's more, they don't fully grasp that DNP-prepared nurses can fill a broad range of roles.

For example, in Nichols' study, CNOs reported they'd most likely hire a DNP-prepared nurse as vice president for patient care, while the least likely role was CEO.

"I think that speaks volumes about a lack of knowledge about who we are, what we do, and what we can bring to the table," Nichols says.

The CNOs' responses to an open-ended invitation to share their thoughts about the DNP degree and employment of DNP-prepared nurses seem to validate Nichols' observation.

She shared some responses from the study:

• "Having a DNP [prepared nurse] would be wonderful, however, we don't require that level of preparation for any of our current positions and given the uncertain state of healthcare reimbursement, we'll not be creating positions requiring DNP-prepared nurses."
• "So far there is not a good understanding by other disciplines of what makes this different or better than MSNs."

Confusion about DNP-prepared nurses "is a real issue," she says. "We as DNPs need to be able to articulate what we bring to the table above and beyond an MSN-prepared nurse and why we're going into this doctorally prepared realm."

As someone who began her APRN career with an MSN, Nichols understands the differences between the two degrees. DNP students obviously face more hours of theory, research, and clinical time than their MSN counterparts, but they also start to assess patient care and the healthcare system's needs in a new way.

"I used to think, 'This is what I do: I diagnose and I treat,' " she says. "Now I have to ask, 'Where else does this patient go? What other kind of direction can I give them?' "

Her expanded perspective goes beyond getting the most appropriate care for her patients.

"I have a far better grasp now, coming out the other end, of what it means to be an APRN than did I going in," says Nichols. "Now I see myself working within a healthcare setting that's part of a much larger setting, as well as the whole piece of who we are as Karmanos Cancer Institute in relation to the rest of the healthcare system in the Detroit Metropolitan area, the state, and the nation. I pretty much never thought of that before and never connected with it before."

Nichols describes her thinking as more global and holistic now since she completed her DNP.

"I see DNPs being leaders within healthcare, definitely in nursing, guiding our nursing discipline through this maze we call America's healthcare system," she says. "I see DNP-prepared nurses increasing access to healthcare and being leaders and developing programs."

DNPs: The role of the future?

So does Karmanos' senior vice president and CNO, Karen Goldman, MSN, RN, AOCN. While Nichols' study found that employers had some uncertainty about DNP-prepared nurses, Goldman is a CNO with a very clear vision of what those nurses can do.

Even though she does not have a DNP herself—she is an MSN-prepared nurse practitioner with a minor in administration—Goldman has incorporated DNP-prepared nurses into the nurse leadership team at Karmanos. In addition to Nichols, Lisa Chism, DNP, GNP-BC, NCMP, FAANP—who wrote a book titled The Doctor of Nursing Practice: A Guidebook for Role Development and Professional Issues—is clinical director and nurse practitioner at Karmanos' Women's Wellness Clinic. Goldman also encouraged Karmanos nurse practitioner Lisa Zajac, MSN, APRN-BC, OCN, to go back to school to pursue a DNP to better prepare her to achieve her goal of becoming a CNO.

"To me, [the DNP] is the perfect role to take nursing leadership to the next level," says Goldman. "I'm at the end of my career right now, but [there were things] I had to learn and pick up on my own, and I see [DNPs] coming out with a much better skill set than I had when I started this role."

Goldman says that because DNP-prepared nurses are educated in complex leadership issues, they are able to contribute to organizations and to healthcare in several ways, including as educators, clinicians, consultants, healthcare policy experts, and advocates.

"I look at the breadth and depth of this degree and I feel it will bring a new era into nursing," she says. "It's going to be the role of the future."