Letter to the Editor on "Doctor of Nursing Practice..."

The Doctor of Nursing Practice (DNP): Need for More Dialogue

October 27, 2006
in response to topic The Doctor of Nursing Practice (DNP): Need for More Dialogue (Sept. 30, 2005)
Dear Editor:

This letter responds to the Doctor of Nursing Practice (DNP) topic. Unlike most professions that require a baccalaureate degree for entry into practice, nursing continues to offer a convoluted, three-tiered approach to undergraduate education for initial licensure of registered nurses (Spear, 2003). On the other (doctoral) end of the nursing educational spectrum is the controversial latest version of the clinical doctorate referred to as the DNP. Some argue the DNP degree is necessary for nursing to progress as a profession, for nurses to provide complex and appropriate care, and for nurses to gain parity with other clinical providers. The National Organization of Nurse Practitioner Faculties (NONFP) and American Association of Colleges of Nursing (AACN) contend that by 2015 the entry level degree for advanced practice should be the DNP (AACN, 2004). Nevertheless, others are not convinced that the mandate for the DNP is wise or warranted (Meleis & Dracup, 2005). Following are some selected reasons for ongoing dialogue and discussion on this critically important topic.

First of all, the title of doctorate in nursing practice is misleading. In talking with undergraduate and graduate nursing students, some nursing educators, and nurses in practice, I have found that many believe that the DNP pertains to nurse practitioners only. Though the NONFP suggested a different title for the practice doctorate for this very reason, given the fact that nurse practitioner groups have been the primary advocates for the DNP, this interpretation of the DNP designation is understandable.

How the DNP has come about, particularly given the seemingly minimal input from other APNs and stakeholders, has contributed to the angst related to this major proposed change in graduate nursing education. If mentioned at all, nurse midwives, nurse anesthetists, and clinical nurse specialists are often given marginal attention in articles and discussions about the DNP. The National Association of Clinical Nurse Specialists (2005) has formally taken a neutral position on the proposed practice doctorate; however, its leadership and constituents have expressed significant concerns regarding the DNP in general and how it will specifically affect future practice.

As an educator, I question how the practice doctorate will play out within the walls of academia. Will DNP-prepared nurses be on equal footing with other doctorally prepared faculty? Granted, nurses with MSN degrees currently teach in both clinical and classroom settings across the country. However, in most university-based nursing programs, MSN-degreed faculty must obtain PhDs or EdDs to advance in professional rank, teach graduate level courses, achieve tenure, and assume leadership roles within the academic infrastructure. To say that DNP-prepared nurses' opportunities for progression as nurse educators is institution specific is less than reassuring (AACN, 2004). I believe that to maximize the potential for professional development and career advancement within the whole realm of nursing education, those who aspire to teach would be best advised to obtain a PhD or EdD instead of the DNP.

Furthermore, some speculate that because DNP programs are perceived as easier, typically do not require dissertations, and may be a shorter route to a doctorate, more nurses will be inclined to seek DNP degrees compared to PhDs which will negatively impact the already small pool of PhD nurse scientists and educators. Despite limited available evidence, those in favor of the DNP claim that this will not happen (O'Sullivan, Carter, Marion, Pohl, & Werner, 2005); however, it seems to be a legitimate concern. Time will tell.

With the push for the DNP degree, a variety of questions regarding the fate of MSN education have surfaced. In contrast to the fragmented model for undergraduate nursing education, most understand what the MSN degree is and what it represents. How will the DNP affect master's education? One theory I've heard proposes that as MSN programs transform into DNP programs, baccalaureate programs will evolve into clinical nurse leader (CNL) master degree programs. Furthermore, though the AACN states otherwise, some speculate that over time the CNL role, differentiated from that of the registered nurse, will become the entry level position for professional nursing practice. Having a separate title and certification exam for CNLs would circumvent the longstanding battle to establish the BSN as the minimum educational requirement for registered nurses and allow the three pathways for licensure to remain in place. Until the future of MSN education is clearly defined and articulated, a variety of theories and rumors will persist.

Opponents and proponents of the clinical doctorate have said in essence, "The horse is already out of the barn." Case in point, across the country 20 DNP programs are currently accepting students and 190 new programs are in various stages of development (AACN, 2006). Even so, continued thoughtful discussion about this evolving paradigm shift in nursing education and advanced practice is warranted to illuminate relevant issues, to answer critical questions, and to do what is best for our profession and the public we serve.

Hila J. Spear, RN, PhD
Professor and Director of Graduate Studies
Department of Nursing
Liberty University
Lynchburg, VA


American Association of Colleges of Nursing. Position statement on the practice doctorate in nursing (2004). Available at www.aacn.nche.edu/DNP/pdf/DNP.pdf.

American Association of Colleges of Nursing. Doctorate in Nursing Practice (DNP) Programs. (2006). Available at www.aacn.nche.edu/DNP/DNPProgramList.htm.

Meleis, A., Dracup, K. (2005). The case against the DNP: History, timing, substance, and marginalization. Online Journal of Issues in Nursing, 19(3), manuscript 2. Available at www.nursingworld.org/MainMenuCategories/OJIN/TableofContents/Volume102005/Number3/tpc28_216026.aspx.

National Association of Clinical Nurse Specialists. White paper on the nursing practice doctorate. (2005). Available at www.nacns.org/nacns_dnpwhitepaper2.pdf.

O'Sullivan, A. L., Carter, M., Marion, L., Pohl, J. M., & Werner, K. E. (2005). Moving forward together: The practice doctorate in nursing. Online Journal of Issues in Nursing, 10(3), manuscript 4. Available at www.nursingworld.org/MainMenuCategories/OJIN/TableofContents/Volume102005/Number3/tpc28_416028.aspx.

Spear, H. J. (2003). The baccalaureate degree for entry into practice: It's time for nursing to take a stand. Nursing Education Today, 23(4), 243-245.