The applicant should read the two proposed articles. After reading both articles, the applicant will reflect on the role of a DNP-prepared nurse in the hea

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Clinical Scholars Review, Volume 8, Number 1, 2015 © Springer Publishing Company 13 http://dx.doi.org/10.1891/1939-2095.8.1.13

DNP/ARNPs AND ComPReheNsive CARe: ADvANCiNg CliNiCAl PRACtiCe

The Necessity of the Doctor of Nursing Practice in

Comprehensive Care for Future Health Care

Michael A. Carter, DNSc, DNP, DCC University of Tennessee Health Science Center

Phillip J. Moore, MSN, FNP-BC University of Tennessee, Knoxville

The education of nurse practitioners has undergone substantial evolution since Ford and Silver (1967) first reported on the preparation of nurses to assume the role of primary care providers for children. From this modest beginning in Colorado emerged a worldwide movement to prepare nurses to diagnose and treat patients in ways that in the past had been restricted to physicians. The early programs were not usually located in schools or colleges of nursing but rather were short-term continuing education programs. Later, nurse practitioner programs were transitioned to master’s degree programs and more recently began to evolve to Doctor of Nursing Practice (DNP) Pro- grams. The American Association of Colleges of Nursing (2014) currently lists 243 active DNP programs and 70 planned programs.

This article examines the historical context for the de- velopment of the Doctor of Nursing Practice (DNP) in comprehensive care. In doing so, there is a consideration of the substantial social and political issues in play dur- ing this evolution. Also covered are the emerging health care issues that mandate a higher level of practice prepa- ration and certification for nurse practitioners who will assume independent practices in the future.

Historical Background of the Doctor of Nursing Practice in Comprehensive Care

Nursing education in the United States has undergone almost constant evolution since the latter part of the 19th century when programs began in hospitals. Pro- grams began a very slow move into American universi- ties in the 1950s, and by the mid-1960s, new programs

emerged to prepare a new product, the nurse practitioner (Ford & Silver, 1967). The creation of nurse practitio- ner programs followed the earlier introduction of pro- grams to prepare nurse anesthetists, nurse midwives, and clinical nurse specialists. The emergence of nurse practitioner programs is interesting in that these pro- grams violated the definition of nursing adopted by the American Nurses Association in 1955. Part of that defi- nition was that nursing specifically did not include acts of diagnosis or prescription of therapeutic or corrective measures (American Nurses Association [ANA], 1955). These early nurse practitioner programs were designed specifically to prepare registered nurses to diagnose and treat patients who presented in a primary care set- ting; treatment entailed prescriptions of drugs as well as other therapeutic and corrective measures (Cockerham & Keeling, 2014).

14 Carter and Moore

of Nursing (AACN) that called for all advanced prac- tice nursing education to transition to the DNP level by 2015. This rapid proliferation of programs created new issues. Few of the programs, beyond the initial ones, were focused on nurse practitioner education. Almost all of the new programs were postmaster’s programs and did not include much, if any, of the supervised clini- cal experience needed to prepare nurse practitioners to provide comprehensive care for patients across various settings. Instead, they added additional general core courses in health policy, economics, epidemiology, and quality improvement. Also, DNP programs focused in health policy, nursing informatics, nursing administra- tion, and similar areas opened that did not have direct care as a focus. At the time of this writing, there are 243 active DNP programs and 70 planned programs listed by the AACN (2014).

Development of Competencies and Certification

In the summer of 2000, the Council for the Advance- ment of Comprehensive Care (CACC) representing the three schools with developing DNP programs; other invited schools with similar interests; and key stake holders in nursing, medicine, and industry held its first international meeting to attempt to reach consen- sus about the standards for practice at the DNP level (CACC, n.d.). The specific focus was how to distin- guish DNP graduates prepared in comprehensive care, from DNP graduates prepared in other specialties. The CACC concluded that there was a need to distinguish DNP graduates who were prepared and could dem- onstrate competency to practice comprehensive care (Carter, 2013). The American Board of Comprehen- sive Care (n.d.) was created by the CACC in 2007 as an independent organization whose purpose would be to develop a certification program for qualified DNP graduates who met this new, higher standard of care delivery. The certification program was accredited by the National Commission for Certifying Agencies in November 2011 (Carter, 2012).

The process of developing a certification examina- tion in comprehensive care required that specific com- petencies be elucidated. The Institute of Credentialing Excellence (2005) identifies two methods for identify- ing clinical competencies for health care practitioners. These are an incumbent job analysis study or logical job analysis. Developing the certification for the DNP in comprehensive care posed a challenge in that there were few DNPs with a practice in comprehensive care

Over the next 35 years, nurse practitioner educa- tion evolved from short-term certificate programs to master’s and postmaster’s programs. This evolution con- tinued as state laws began to require master’s level edu- cation for new graduates who wished to be authorized to prescribe medications and bill for services. Almost from the inception of the new master’s programs was the concern by nursing faculty and the profession that the length and depth of these programs was not suf- ficient for the level of the work expected of the new graduates (Cockerham & Keeling, 2014).

The idea of offering a doctoral degree for nurses had been around for quite a while. The profession had a his- tory of offering research doctoral degrees that began in the 1920s, but there was a rapid growth of these doctoral programs that occurred around the time that nurse prac- titioners’ education was moving into master’s degree pro- grams (Carter, 2006). The first clinical doctoral program, the Doctor of Nursing (ND), began at the Frances Payne Bolton School of Nursing at Case Western Reserve University in 1979 (Standing & Kramer, 2003). Three additional ND programs opened over the next few years (Hathaway, Jacob, Stegbauer, Thompson, & Graff, 2006). Nursing continued to evolve and respond to changes and demands of health care trends. The late 20th and begin- ning of the 21st centuries saw the development of the first work that led to the opening of the first Doctor of Nursing Practice (DNP) programs by three schools: the University of Tennessee Health Science Center in 1999, the University of Kentucky in 2001, and Columbia Uni- versity in 2005 (Hathaway, et al., 2006). The goal of these programs was to craft a clinical doctoral program for ad- vanced practice nurses who would be prepared for a level of practice that had not been previously seen.

The driving force for the creation of these programs at the University of Tennessee Health Science Center and Columbia University emerged from the sophisticated faculty practices of these schools. The faculty in nursing were engaged in practices that mirrored the other health sciences. In these practices, the nursing faculty were in- dependently diagnosing and treating patients, caring for patients across sites, billing for services, educating stu- dents, and conducting clinical research. These programs learned that the traditional master’s programs they had been offering were not sufficient in rigor or focus to pre- pare graduates for independent practice across sites in an evolving health care system (Hathaway et al., 2006).

From these early beginnings, DNP programs began opening rapidly, particularly following the 2004 posi- tion statement by the American Association of College

DNP in Comprehensive Care 15

systems, aggregate models of care for the management of chronic illness, and continuous monitoring of qual- ity of care delivered and improvements where needed (Rittenhouse, Shortell, & Fisher, 2009).

In the past, master’s level nurse practitioners were prepared to deliver care in a private office or clinic setting. Some of the most complex and challenging as- pects of health care, including medication errors and errors in communication, occur when patients transi- tion from home to hospital; from hospital to subacute care setting, such as rehabilitation centers or nursing homes; from subacute settings to home; or to palliative care (Forster, Murff, Peterson, Gandhi, & Bates, 2003). Historically, nurse practitioners did not receive the preparation to provide care across multiple health care sites, yet this is now required to reduce morbidity and mortality. Current clinical information systems do not share across these settings, even though there are new incentives being developed by the Centers for Medicare and Medicaid Services (2014), to attempt to deal with this problem. What is required of nurse practitioners, however, is that they must be competent to understand the systems of care in the various settings in which care is delivered and the ways in which patients are treated in these sites of care. Nurse practitioners who are pre- pared in comprehensive care have these competencies, which are not part of other nurse practitioner educa- tion programs (Thomas et al., 2012), because these competencies are built into the DNP programs in com- prehensive care and tested on the American Board of Comprehensive Care.

The ACA is opening the doors to care for millions of Americans who did not previously have access to care because they were uninsured or underinsured. The White House (2014) reports that about 20 million people have insurance today that did not have insurance last year under the previous system; this insurance coverage in- cludes at a minimum primary care, specialist care, hos- pital care, and preventive care. Nurse practitioners will provide care to many of the millions of new enrollees.

Evidence exists that there will be substantial new demands for care from these newly insured individuals. In 2006, Massachusetts began their move to provide insurance coverage for all the people of the state and the Massachusetts’ insurance program shares many of the key components of the ACA (Henry J. Kaiser Family Foundation, 2012). This experience by Massa- chusetts can serve as an indicator as to what the rest of the country might expect with full implementation of the ACA. The Henry J. Kaiser Family Foundation

to support an incumbent job analysis. There was other work, however, that could assist with the logical job analysis. The AACN (2006) had released its document entitled The Essentials of Doctoral Education for Advanced Nursing Practice in 2006, the same year the National Organization of Nurse Practitioner Faculties (NONPF, 2006) released their competencies for the DNP. These documents, combined with the work of the CACC, formed the basis for the logical job analysis.

Designing a national certification examination with appropriate psychometrics is a very complex un- dertaking. The National Board of Medical Examiners (NBME), an organization with a long history in devel- oping such examinations for health care professionals, entered into a contract with the American Board of Comprehensive Care to design and administer the com- prehensive care examination and to use the logical job analysis as the basis of the examination (National Board of Medical Examiners [NBME], n.d). The purpose of the examination was to “assess the knowledge and skills necessary for nurse clinicians to provide safe and ef- fective patient-centered comprehensive care” (NBME, n.d., p. 2). The first examination was administered in 2008 (Carter, 2012).

By 2011, a cohort of DNPs had graduated, were certified, and agreed to participate in the first incum- bent job analysis study of DNPs in comprehensive care (Honig, Smolowitz, & Smaldone, 2011). This job analy- sis confirmed the competencies identified by the logical job analysis that had been performed earlier by the ex- perts for the American Board of Comprehensive Care.

Emerging Health Care Trends Requiring Different Nurse Practitioners

There are several changes taking place in the health care system of the United States which call for additional preparation for future nurse practitioners. The Patient Protection and Affordable Care Act, commonly short- ened to the Affordable Care Act (ACA; U.S. Congress, 2010), is changing the way primary care is delivered, in- cluding the creation of patient-centered medical homes. This model of care is designed to improve the quality of primary care delivered in the United States and at a lower cost. The critical element of first-contact for care remains in the patient-centered medical homes, but there are new requirements that the care be con- tinuous, comprehensive, and coordinated across the care continuum (U.S. Congress, 2010). The promise is that this care will make use of new electronic information

16 Carter and Moore

help bring some logical order to conflicting plans of care by different groups and to work to bring about the desired end of life including palliative care when needed. Previous educational programs for nurse practitioners just did not provide this expertise. These are the competencies of the DNP who is prepared in comprehensive care.

Conclusion

The health care system of the United States is experi- encing several dramatic changes in the way care is de- livered, and nurses will play a major role in bringing about these changes. What is likely to occur is increased demand for primary care but not the primary care of the past. Clearly there will remain the requirements of first-contact for care by a professional who will likely work in teams of care. But no longer can this care be built on discrete episodes of care. In the future, this care will be required to be continuous across episodes, pro- vide comprehensive services including new emphasis on health promotion and disease prevention, and be highly coordinated across the care continuum. To do less fails to provide the expected quality of care and places the patient in potential harm.

Nurse practitioners have long proven their expertise in delivering primary care services to a variety of patient populations in many geographic regions. These past suc- cesses have been well documented but will not be suffi- cient for the emerging health care system. Also, the pre- vious models of nurse practitioner education will not be sufficient. New medical advances will bring challenges in helping patients navigate systems and modalities of care that are much different than what is seen today. As options and choices in care expand, so too expands the need for nurse practitioners who can help select the best options and make the best choices for the individ- ual patient. Only the diplomates in comprehensive care have the documented knowledge, skills, and abilities to be the guide to care that is demanded now and will be in even greater demand in the future.

Harm to patients through medical errors, lack of communication, and poor judgment by clinicians should be avoided at all cost. These potentially fatal errors can be avoided by nurse practitioners who possess the re- quired competencies that are a part of the DNP in com- prehensive care. With the cadre of exquisite clinicians that are being prepared and certified to provide com- prehensive care, nurse practitioners will lead the way in a reformed health care system.

(2012) indicated that by 2010, Massachusetts reported 6.3% of the population was uninsured compared to 18.4% for the rest of the United States. The people of Massachusetts are more likely to have a usual source of care other than the hospital emergency room and are more likely to have had a preventive care visit in the last year compared the rest of the United States (Henry J. Kaiser Family Foundation, 2012). In addition, there were substantial declines in all-cause mortality and mortality from causes amenable to health care following the implementation of the near universal coverage in Massachusetts (Sommers, Long, & Baicker, 2014). One of the most dangerous times for patients is the transi- tion from one site of care to another (Naylor, Aiken, Kurtzman, Olds, & Hirschman, 2011). These transitions are where the largest amount of morbidity and mortal- ity occur. The emerging new demands for care from a reformed health care system call for DNP nurse prac- titioners to be educated in new models of comprehen- sive care to assure that the lessons from the past will be shared with the rest of the nation.

Along with a reformed structure for payment, the American health care system is beginning to under- stand the many challenges posed by an aging popula- tion. There were more than 43 million older Americans in 2012, and this is expected to grow to 56 million by 2020 (U.S. Department of Health and Human Ser- vices, 2013). The Agency on Aging (U.S. Department of Health and Human Services, 2013) provides some sobering statistics: Only 42% of older Americans report their health to be excellent or very good, and most have at least one chronic condition with many having sev- eral. The most common conditions experienced by older Americans include hypertension (72%), arthritis (50%), heart disease (30%), cancer (24%), and diabetes (20%) and often more than one condition can exist at the same time for the same patient. These health problems illustrate the level of care required for this age group compared to younger age groups. Americans older than 75 years of age are substantial users of care with 23% visiting their primary care practitioner or specialist on average of 10 or more times per year, and the rate of hos- pitalization for Americans older than 65 years is three times that of younger Americans (U.S. Department of Health and Human Services, 2013).

Nurse practitioners of the future will need enhanced skills and knowledge of how to help these older Americans navigate the multiple sites of care and myriad of diverse providers and specialists. Nurse practitioners are poised to

DNP in Comprehensive Care 17

Honig, J., Smolowitz, J., & Smaldone, A. (2011). APRN survey on roles, functions, and competencies. Clinical Scholars Review, 4(1), 15–19.

Institute of Credentialing Excellence. (2005). National Commis- sion for Certifying Agencies (NCCA) standards. Retrieved from http://www.credentialingexcellence.org/p/cm/ld/fid=66

National Board of Medical Examiners. (n.d.). NBME deve- lopment of a certifying examination for doctors of nursing practice. Retrieved from http://www.nbme.org/pdf/nbme- development-of-dnp-cert-exam.pdf

National Organization of Nurse Practitioner Faculties. (2006). Practice doctorate nurse practitioner entry-level competencies 2006. Retrieved from http://c.ymcdn.com/sites/www.nonpf .org/resource/resmgr/competencies/dnp%20np%20 competenciesapril2006.pdf

Naylor, M. D., Aiken, L. H., Kurtzman, E. T., Olds, D. M., & Hirschman, K. B. (2011). The care span: The importance of transitional care in achieving health reform. Health Affairs, 30(4), 746–754.

Rittenhouse, D., Shortell, S., & Fisher, E. (2009). Primary care and accountable care—Two essential elements of delivery-system reform. New England Journal of Medicine, 36, 2301–2303.

Sommers, B., Long, S., & Baicker, K. (2014). Changes in mortality after Massachusetts health care reform: A quasi-experimental study. Annals of Internal Medicine, 160, 585–593.

Standing, T. S., & Kramer, F. M. (2003). The ND: Preparing nurses for clinical and educational leadership. Reflections on Nursing Leadership, 29(4), 35–37, 44.

The White House. (2014). Fact sheet: Affordable care act by the numbers. Retrieved from http://www.whitehouse.gov/ the-press-office/2014/04/17/fact-sheet-affordable-care- act-numbers

Thomas, A. C., Crabtree, M. K., Delaney, K. R., Dumas, M. A., Kleinpell, R., Logsdon, M. C., . . . Nativio, D. G. (2012). Nurse practitioner core competencies. Retrieved from http://c.ymcdn.com/sites/www.nonpf.org/resource/ resmgr/competencies/npcorecompetenciesfinal2012.pdf

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U.S. Department of Health and Human Services. (2013). A profile of older Americans: 2013. Retrieved from http:// www.aoa.gov/Aging_Statistics/Profile/index.aspx

Correspondence regarding this article should be directed to Michael A. Carter, DNSc, DNP, DCC, University of Tennessee Health Science Center, Memphis, TN 38163. E-mail: mcarter@ uthsc.edu

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Enhancing Nurse Moral Agency: The Leadership Promise of Doctor of Nursing Practice Preparation

^ m d

Abstract

…it is more critical than ever that we remain mindful about the demands of ‘good’ patient care.

The development of knowledgeable and skillful nurse leaders is necessary to enhance interdisciplinary

Pamela Grace, PhD, RN, FAAN

An expansive and growing body of literature documents the problem of nurses’ moral distress when they are unable to carry out actions that they perceive to be in the best interests of patients. Further, nurse leaders and educators are not always well prepared to help nurses to develop moral agency. Moral agency is the ability to provide good care and overcome obstacles to good practice. One reason for the lack of preparation is that ethics education in academia, and in ongoing nurse education, has been inconsistent or has focused more on dilemmas than the ubiquitous everyday practice issues. The purpose of this article is to discuss goals of the nursing profession, contemporary challenges to good nursing practice, and leadership from those educated as Doctors of Nursing Practice (DNP). The author argues that the proliferation of (DNP) programs, focused as they are on leadership in practice settings, presents a unique opportunity to prepare nurse leaders who are, first and foremost, skilled and knowledgeable about the ethical content of everyday nursing practice. An ‘ethics matrix’ is described and proposed as an essential base for DNP education upon which all other knowledge is built, with specific discussion of types of leadership and the relationship of transformational learning to transformational leadership.

Citation: Grace, P., (January 31, 2018) "Enhancing Nurse Moral Agency: The Leadership Promise of Doctor of Nursing Practice Preparation" OJIN: The Online Journal of Issues in Nursing Vol. 23, No. 1, Manuscript 4.

DOI: 10.3912/OJIN.Vol23No01Man04

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