Springer Publishing's journal Clinical Scholars Review's latest issue is all about the topic of Doctor of Nursing Practice (DNP) degrees and their role in comprehensive care. In the coming days, we will be posting several Q&A with authors whose work is published in this issue; for more, the journal can be read online here.

by Michael A. Carter, DNSc, DNP, DCC and Michael and Phillip J. Moore, MSN, FNP-BC

What distinguishes a DNP degree from other advanced practice nursing degrees?

In the United States (US) today, there are two types of academic degrees that are used for the preparation of advanced practice nurses.  These are the Master’s degree and the Doctor of Nursing Practice (DNP) degree.  The Master’s degree has been used for several decades while the DNP is more recent.  DNP programs are usually longer in length and some programs may require that the student already hold a Master’s degree to be admitted to the DNP program.  The American Association of College of Nursing has identified the essentials for the Master’s and DNP degrees  and you can find these at: http://www.aacn.nche.edu/education-resources/MasEssentials96.pdf and http://www.aacn.nche.edu/publications/position/DNPEssentials.pdf  These essentials share some aspects but also have a number of differences.

All of this can seem a bit confusing.  That is because there are hundreds of programs and each of these often reflect the unique issues of the College or University that offers the program and how they apply the various national standards.  Guidelines are just that, guidelines – they are not mandated requirements.  Also, as you look through this information, you will find that the guidelines are very general.

An important consideration to remember is that all DNP programs do not focus on APRN education.  In fact, many do not.  They focus in areas such as administration, health policy, informatics and other areas that do not provide actual additional clinical education.  To confuse the picture even more, some DNP programs prepare APRNs such as CRNA’s and CNM’s while others focus on nurse practitioner preparation.

How does the current healthcare environment demand a DNP degree? 

 Many changes are taking place in the healthcare environment around the world.  Almost all of these changes demand better preparation for nurses practicing at the highest level.  In most countries, advanced practice nursing is a reflection of the organization, administration, and funding of the healthcare system.  The US is no exception.  The US healthcare system is a mixture of private and public systems, organized around mostly a fee-for-service payment arrangement, and administered by a variety of different organizations with different goals.  There is not a single, unified system of care in the US.  The Affordable Care Act (ACA) that began in 2010 brought with it many changes in the way care is delivered, to whom it is delivered, how it is paid for and new mandates for quality considerations.

Nurses with DNPs have important roles as the ACA continues to roll out.  However, one of the most critical roles for advanced practice nurses in is primary care.  Primary care is the basis for all of the rest of the system and the ACA has greatly expanded demand for and the expectations of primary care providers.  The Centers for Medicare and Medicaid Services (CMS) currently covers over 100 million people in the US.  In their document outlining the road ahead in health care (http://www.cms.gov/About-CMS/Agency-Information/CMS-Strategy/Downloads/CMS-Strategy.pdf), CMS outline that they will focus in four areas:  Better Care and Lower Costs; Prevention and Population Health; Expanded Health Coverage; and Enterprise Excellence.  All of these goals require a robust primary care delivery system.  Yet, we know that past approaches to primary care that only considered physicians will not work for at least two reasons.  First, there are insufficient primary care physicians now to be the single provider of primary care and even fewer are being prepared for the future.  Nurse practitioners are a critical dimension of the care delivery system today and tomorrow.  Second, past approaches to primary care education for both physicians and nurse practitioners have not included some of the critical areas needed by this expanded system.  There is insufficient effort directed toward helping patients with multiple co-morbidities make sense of the often competing recommendations for management.  There is a lack of understanding about how to help minimize the potential mortality and morbidity that occurs when transitioning across setting of care or different providers of care.  And, third, there is a paucity of mental health care delivered by primary care providers.

We simply must do better and this means that the Master’s preparation of nurse practitioners is no longer sufficient for tomorrow’s primary care provider.  But the DNP degree alone is not the issue.  The degree is important because these programs are longer and more intense.  But the DNP primary care practitioner program must also focus on increased clinical learning requirements in the areas now needed in primary care.  Earning a Master’s degree in primary care nursing and adding a DNP in administration, or general education does not provide this level of clinical education to tomorrow’s primary care practitioner.  Only the DNP in comprehensive care provides this level of knowledge, skills and abilities for the nurse practitioner.

What are the goals of DNP programs in Comprehensive Care?

The DNP programs in comprehensive care focus on preparing the primary care clinician for the emerging future.  These programs include the usual preparation in basic sciences, differential diagnosis, laboratory and radiography along with knowledge and clinical skills in treating a broad array of acute and chronic conditions.  The added clinical expertise deals with the challenges that we see when patients move across care settings – office to ER to inpatient service – to ICU – to rehabilitation – to home and back to office.  There are challenges when the patient has been evaluated and treatment recommended by numerous medical and other specialists who do not communicate with each other or who do not know the whole picture of the patient. This level of learning requires that the students are mentored to care for panels of patients that they follow over time and to design treatment and evaluation of care that deals with these unique concerns.  Past preparation in only one site of care – the office, as seen in most Master’s programs – is insufficient to gain this perspective.  Tomorrow’s primary care APRN must be able to balance competing recommendations for care with the unique situation of the patient and this is based on a continuing relationship with the patient across settings.  We must understand how moving from the ICU to the nursing home can result in substantial harm or even death to the patient.  And, we clearly must do a much better job teaching our APRNs to provide mental health to primary care patients.  We do not ignore or refer all the cardiac care for a patient yet we do that very thing now for mental health care to the detriment of the patient.

Nursing is the one health profession in which the very epistemological basis of our field is predicated on understanding the whole person in context.  This means that we nurses know that a person with hypertension is a person first, who lives a life that is whole and integrated in the context of family and community.  Therefore, any treatment recommendations that we make must always be vetted in the context of how these treatments will fit in the person’s life.  This is a subtle but powerfully critical different perspective that nursing along brings to the care encounter. There are a number of ways that hypertension can be treated but perhaps only a few ways that a particular patient should be treated for hypertension, if we understand the unique nature of the particular patient.