Impact of the Doctor of Nursing Practice degree on nursing certification

Should the Doctor of Nursing Practice (DNP) degree be the entry point to advanced practice nursing by 2015? Should current master’s-level exams for advanced practice registered nurses (APRNs) be redesigned? What structure should be used to develop the DNP-level certification exams? What does the DNP degree mean for current APRNs and other graduates of nursing masters programs? These are just some of the questions surrounding the DNP that have led to significant confusion and some disagreement.

The plan by the American Association of Colleges of Nursing (AACN) to make the DNP the entry point for advanced practice nursing by 2015 has several clear benefits. Because many nursing masters programs are credit heavy, graduates of those programs already are taking credit loads that would equal those of doctoral programs. A doctoral degree would allow these graduates to receive the educational degree that matches their extensive academic accomplishments.

The heavy credit loads in APRN masters programs also indicate the steady advance of knowledge and skills required to practice at the advanced level and the concomitant need for more intensive education for today’s APRN. Also, a doctoral degree will permit nurses to achieve degree parity with other healthcare professions. As noted by Elizabeth R. Lenz, PhD, RN, FAAN, in the Online Journal of Issues in Nursing (Volume 10, Issue 3, 2005), “parity for nursing is not simply a matter of status. Instead, it is increasingly the credential that is needed for credibility in leadership positions. The Task Force on the Practice Doctorate in Nursing concluded, based upon comments from the administrative experts with whom the task force met, that nurses who have earned the doctoral degree with a practice focus will be more likely than their master’s-prepared counterparts to be accorded a place at the table in institutional and health system decision making.”

The nursing profession is dynamic. It has developed as society and the healthcare system have developed, and continues to respond to ongoing changes in the healthcare environment. As nursing has evolved, so has nursing education. Less than a century ago, all nurses entered practice through hospital-based diploma programs. Since university-based nursing education programs were introduced in the early 20th century, nursing education has developed steadily. Today, almost all nurses enter practice via academic programs, including a growing numbers of graduate-prepared nurses.

Two general types of doctorates in nursing are available: research-focused and practice-focused. Although practice doctorates have been around for a long time, historically most nursing doctorates have had an academic or research focus and have bestowed either a PhD (Doctor of Philosophy) or DNSc (Doctor of Nursing Science) degree.

The DNP is not the first practice-focused nursing degree at the doctoral level. The Doctor of Nursing degree was introduced more than two decades ago, although it never gained the traction or created the controversy that surrounds the DNP; also, DNP programs have mostly supplanted it.

According to Mary Smolenski, EdD, FNP, FAANP, CAE, director of certification at the American Nurses Credentialing Center (ANCC), “The controversy surrounding the DNP relates chiefly to the relationship between education, certification, and licensing at the advanced practice level. However, change in APRN education is not new but part of a continuing evolution that has occurred as the healthcare system and nursing practice have grown increasingly complex. Educational preparation for advanced practice RN roles has moved from the certificate model to the master’s level to the DNP, which is a natural and gradual progression.”

Karen Macdonald, MS, FNP-BC, chair of the ANCC Commission on Certification, stated, “ANCC began to proactively monitor and evaluate the potential impact of the DNP on credentialing in early 2007, after AACN released their DNP Roadmap Task Force Report in October 2006.” ANCC’s response, she said, was to form its own task force to look at the impact of the DNP on certification. The ANCC Task Force, chaired by ANCC past president Dr. Patricia Yoder-Wise, EdD, RN, NEA-BC, ANEF, FAAN, convened in December 2007 and developed a survey that initially was sent to key nursing leaders in nursing education, certification, and licensure stakeholder organizations. (See DNP survey review groups in the downloadable pdf available at the bottom of this page.)

“The purpose of the survey was to review the DNP and its implications for advanced practice nursing certifications,” said Macdonald, who was also a member of the ANCC DNP Task force.
The original group of invited responders helped ANCC revise the survey, which was posted on the ANCC website and distributed by many of the other nursing groups that participated in the initial survey.

Macdonald said that “the 4,284 responses received provide the most comprehensive picture yet on the views of nurses in the field. One key question addressed by the survey was what was envisioned as the ideal future for certification of nurses holding the DNP degree in 2015. A majority of respondents (59.7%) expressed a preference for a single comprehensive end-point certification, with DNP degrees required for entry into all advanced practice nursing.”
However, Macdonald noted, the overall results were not definitive and pointed to a need for enhanced communication to clarify understanding and expectations among nurses. “There was a lot of confusion about this issue, and we feel that continued efforts to enhance and ensure the clarity and transparency of communications around the issue will really help,” she said.

“There seems to be a consensus that action is needed,” stated Smolenski, “but no clear idea of what that action is. The evidence for defining and clarifying the new role of the DNP-prepared nurse in any advanced specialty will present itself over time,” she added.

As Yoder-Wise noted, “We don’t yet have enough DNP graduates to do a role-delineation study.…If it doesn’t change the role, why would we change the test? The question we need to answer is whether what we are doing is adding knowledge that is useful but that does not significantly change the role, or are we seeing new knowledge, new abilities, new expectations?”

There seems to be significant support for the current system of APRN certification and a demand for an evidence-based approach to any significant changes. Noted Mary Dumas, PhD, RN, FNP-BC, FAANP, President of the National Organization of Nurse Practitioner Faculties (NONPF), “NONPF does not endorse or promote to our members any particular certification process for nurse practitioners (NPs). There is consistent support among the NP community for sustaining the existing national NP certification exams that focus on the role and the patient population in which the NP has been educated (such as pediatrics, adult, and family). These examinations are recognized by regulators, upon which NPs are granted clinical practice privileges by the state Board of Nursing under the state’s nurse practice act.”
“Certification bodies and specialty organizations are not going to run out and make changes until the evidence is there to support it,” said Smolenski. “However, certification bodies do adapt gradually as education and practice develop.” Yoder-Wise noted, “Certification that validates the knowledge and skills or competencies of nursing roles must evolve as the practice evolves.”

According to Macdonald, discussion and analysis of the implications of the DNP for APRN certification underscore the interrelated nature of the current model of nursing education, credentialing, and regulation. “It highlights the importance of cooperation and consensus-building between many stakeholders with a keen eye on the interests and needs of the nurses and the public and the final impact on patient outcomes.”

Macdonald noted that the ANA Board of Directors recently endorsed the Consensus Model for APRN Regulations: Licensure, Accreditation, Certification and Education. “The Consensus Model shows the way forward in how we need to cooperate,” she said. “We believe the same level of cooperation should be employed in assessing and responding to the issues raised by the DNP. When nursing organizations cooperate, nurses and the public benefit.”

Todd Peterson is Senior Communications Specialist for the American Nurses Credentialing Center, a subsidiary of ANA.

For more information, see:
•    AACN’s DNP Road Map Task Force Report (2006). Available at www.aacn.nche.edu/DNP/pdf/DNProadmapreport.pdf.
•    Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education (July 7, 2008). Available at www.nursingworld.org/DocumentVault/APRNs/ConsensusModelforAPRNRegulation.aspx.
•    Practice Doctorate Resource Center, National Organization of Nurse Practitioner Faculties. Available at www.nonpf.org/NONPF2005/PracticeDoctorateResourceCenter/PDResourceCenter.htm.