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Minnesota State University, Mankato

Minnesota State University, Mankato

Student Handbook — Appendix A

Page address: http://ahn.mnsu.edu/nursing/graduate/dnpstudhdbk_appendixa.html

The Essentials of Doctoral Education for Advanced Nursing Practice

Essential I: Scientific Underpinnings for Practice

The practice doctorate in nursing provides the terminal academic preparation for nursing practice. The scientific underpinnings of this education reflect the complexity of practice at the doctoral level and the rich heritage that is the conceptual foundation of nursing.

The discipline of nursing is focused on:

  • The principles and laws that govern the life-process, well-being, and optimal function of human beings, sick or well;
  • The patterning of human behavior in interaction with the environment in normal life events and critical life situations;
  • The nursing actions or processes by which positive changes in health status are affected; and
  • The wholeness or health of human beings recognizing that they are in continuous interaction with their environments (Donaldson & Crowley, 1978; Fawcett, 2005; Gortner, 1980).

DNP graduates possess a wide array of knowledge gleaned from the sciences and have the ability to translate that knowledge quickly and effectively to benefit patients in the daily demands of practice environments (Porter-O'Grady, 2003). Preparation to address current and future practice issues requires a strong scientific foundation for practice. The scientific foundation of nursing practice has expanded and includes a focus on both the natural and social sciences. These sciences that provide a foundation for nursing practice include human biology, genomics, and science of therapeutics, the psychosocial sciences, as well as the science of complex organizational structures. In addition, philosophical, ethical, and historical issues inherent in the development of science create a context for the application of the natural and social sciences. Nursing science also has created a significant body of knowledge to guide nursing practice and has expanded the scientific underpinnings of the discipline. Nursing science frames the development of middle range theories and concepts to guide nursing practice. Advances in the foundational and nursing sciences will occur continuously and nursing curricula must remain sensitive to emerging and new scientific finding to prepare the DNP for evolving practice realities.

The DNP program prepares the graduate to:

  1. Integrate nursing science with knowledge from ethics, the biophysical, psychosocial, analytical, and organizational sciences as the basis for the highest level of nursing practice.
  2. Use science-based theories and concepts to:
    • determine the nature and significance of health and health care delivery phenomena;
    • describe the actions and advanced strategies to enhance, alleviate, and ameliorate health and health care delivery phenomena as appropriate; and
    • evaluate outcomes.
  3. Develop and evaluate new practice approaches based on nursing theories and theories from other disciplines.

Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking

Organizational and systems leadership are critical for DNP graduates to improve patient and healthcare outcomes. Doctoral level knowledge and skills in these areas are consistent with nursing and health care goals to eliminate health disparities and to promote patient safety and excellence in practice.

DNP graduates' practice includes not only direct care but also a focus on the needs of a panel of patients, a target population, a set of populations, or a broad community. These graduates are distinguished by their abilities to conceptualize new care delivery models that are based in contemporary nursing science and that are feasible within current organizational, political, cultural, and economic perspectives.

Graduates must be skilled in working within organizational and policy arenas and in the actual provision of patient care by themselves and/or others. For example, DNP graduates must understand principles of practice management, including conceptual and practical strategies for balancing productivity with quality of care. They must be able to assess the impact of practice policies and procedures on meeting the health needs of the patient populations with whom they practice. DNP graduates must be proficient in quality improvement strategies and in creating and sustaining changes at the organizational and policy levels. Improvements in practice are neither sustainable nor measureable without corresponding changes in organizational arrangements, organization and professional culture, and the financial structures to support practice. DNP graduates have the ability to evaluate the cost effectiveness of care and use principles of economics and finance to redesign effective and realistic care delivery strategies. In addition, DNP graduates have the ability to organize care to address emerging practice problems and the ethical dilemmas that emerge as new diagnostic and therapeutic technologies evolve. Accordingly, DNP graduates are able to assess risk and collaborate with others to manage risks ethically, based on professional standards.

Thus, advanced nursing practice includes an organizational and systems leadership component that emphasizes practice, ongoing improvement of health outcomes, and ensuring patient safety. In each case, nurses should be prepared with sophisticated expertise in assessing organizations, identifying systems' issues, and facilitating organization-wide changes in practice delivery. In addition, advanced nursing practice requires political skills, systems thinking, and the business and financial acumen needed for the analysis of practice quality and costs.

The DNP program prepares the graduate to:

  1. Develop and evaluate care delivery approaches that meet current and future needs of patient populations based on scientific findings in nursing and other clinical sciences, as well as organizational, political, and economic sciences.
  2. Ensure accountability for quality of health care and patient safety for populations with whom they work.
    1. Use advanced communication skills/processes to lead quality improvement and patient safety initiatives in health care systems.
    2. Employ principles of business, finance, economics, and health policy to develop and implement effective plans for practice-level and/or system-wide practice initiatives that will improve the quality of care delivery.
    3. Develop and/or monitor budgets for practice initiatives
    4. Analyze the cost-effectiveness of practice initiatives accounting for risk and improvement of health care outcomes.
    5. Demonstrate sensitivity to diverse organizational cultures and populations, including patients and providers.
  3. Develop and/or evaluate effective strategies for managing the ethical dilemmas inherent in patient care, the health care organization, and research.

Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice

Scholarship and research are the hallmarks of doctoral education. Although basic research has been viewed as the first and most essential form of scholarly activity, an enlarged perspective of scholarship has emerged through alternative paradigms that involve more than discovery of new knowledge (Boyer, 1990). These paradigms recognize that (1) the scholarship of discovery and integration "reflects the investigative and synthesizing traditions of academic life" (Boyer, p.21); (2) scholars give meaning to isolated facts and make connections across disciplines through the scholarship of integration; and (3) the scholar applies knowledge to solve a problem via the scholarship of application (referred to as the scholarship of practice in nursing). This application involves the translation of research into practice and the dissemination and integration of new knowledge, which are key activities of DNP graduates. The scholarship of application expands the realm of knowledge beyond mere discovery and directs it toward humane ends. Nursing practice epitomizes the scholarship of application through its position where the sciences, human caring, and human needs meet and new understandings emerge.

Nurses have long recognized that scholarly nursing practice is characterized by the discovery of new phenomena and the application of new discoveries in increasingly complex practice situations. The integration of knowledge from diverse sources and across disciplines, and the application of knowledge to solve practice problems and improve health outcomes are only two of the many ways new phenomena and knowledge are generated other than through research (AACN, 1999; Diers, 1995; Palmer, 1986; Sigma Theta Tau International, 1999). Research-focused doctoral programs in nursing are designed to prepare graduates with the research skills necessary for discovering new knowledge in the discipline. In contrast, DNP graduates engage in advanced nursing practice and provide leadership for evidence-based practice. This requires competence in knowledge application activities: the translation of research in practice, the evaluation of practice, improvement of the reliability of health care practice and outcomes, and participation in collaborative research (DePalma & McGuire, 2005). Therefore, DNP programs focus on the translation of new science, its application and evaluation. In addition, DNP graduates generate evidence through their practice to guide improvements in practice and outcomes of care.

The DNP program prepares the graduate to:

  1. Use analytic methods to critically appraise existing literature and other evidence to determine and implement the best evidence for practice.
  2. Design and implement processes to evaluate outcomes of practice, practice patterns, and systems of care within a practice setting, health care organization, or community against national benchmarks to determine variance in practice outcomes and population trends.
  3. Design, direct, and evaluate quality improvement methodologies to promote safe, timely, effective, efficient, equitable, and patient-centered care.
  4. Apply relevant findings to develop practice guidelines and improve practice and the practice environment.
  5. Use information technology and research methods appropriately to:
    • collect appropriate and accurate data to generate evidence for nursing practice
    • inform and guide the design of databases that generate meaningful evidence for nursing practice
    • analyze data from practice
    • design evidence-based interventions
    • predict and analyze outcomes
    • examine patterns of behavior and outcomes
    • identify gaps in evidence for practice
  6. Function as a practice specialist/consultant in collaborative knowledge-generating research.
  7. Disseminate findings from evidence-based practice and research to improve healthcare outcomes.

Essential IV: Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care

DNP graduates are distinguished by their abilities to use information systems/technology to support and improve patient care and healthcare systems, and provide leadership within healthcare systems and/or academic settings. Knowledge and skills related to information systems/technology and patient care technology prepare the DNP graduate to apply new knowledge, manage individual and aggregate level information, and assess the efficacy of patient care technology appropriate to a specialized area of practice. DNP graduates also design, select, and use information systems/technology to evaluate programs of care, outcomes of care, and care systems. Information systems/technology provide a mechanism to apply budget and productivity tools, practice information systems and decision supports, and web-based learning or intervention tools to support and improve patient care.

DNP graduates must also be proficient in the use of information systems/technology resources to implement quality improvement initiatives and support practice and administrative decision-making. Graduates must demonstrate knowledge of standards and principles for selecting and evaluating information systems and patient care technology, and related ethical, regulatory, and legal issues.

The DNP program prepares the graduate to:

  1. Design, select, use, and evaluate programs that evaluate and monitor outcomes of care, care systems, and quality improvement including consumer use of health care information systems.
  2. Analyze and communicate critical elements necessary to the selection, use and evaluation of health care information systems and patient care technology.
  3. Demonstrate the conceptual ability and technical skills to develop and execute an evaluation plan involving data extraction from practice information systems and databases.
  4. Provide leadership in the evaluation and resolution of ethical and legal issues within healthcare systems relating to the use of information, information technology, communication networks, and patient care technology.
  5. Evaluate consumer health information sources for accuracy, timeliness, and appropriateness.

Essential V: Health Care Policy for Advocacy in Health Care

Health care policy—whether it is created through governmental actions, institutional decision making, or organizational standards—creates a framework that can facilitate or impede the delivery of health care services or the ability of the provider to engage in practice to address health care needs. Thus, engagement in the process of policy development is central to creating a health care system that meets the needs of its constituents. Political activism and a commitment to policy development are central elements of professional nursing practice, and the DNP graduate has the ability to assume a broad leadership role on behalf of the public as well as the nursing profession (Ehrenreich, 2002). Health policy influences multiple care delivery issues, including health disparities, cultural sensitivity, ethics, and the internationalization of health care concerns, access to care, quality of care, health care financing, and issues of equity and social justice in the delivery of health care.

DNP graduates are prepared to design, influence, and implement health care policies that frame health care financing, practice regulation, access, safety, quality, and efficacy (IOM, 2001). Moreover, the DNP graduate is able to design, implement and advocate for health care policy that addresses issues of social justice and equity in health care. The powerful practice experiences of the DNP graduate can become potent influencers in policy formation. Additionally, the DNP graduate integrates these practice experiences with two additional skill sets: the ability to analyze the policy process and the ability to engage in politically competent action (O'Grady, 2004).

The DNP graduate has the capacity to engage proactively in the development and implementation of health policy at all levels, including institutional, local, state, regional, federal, and international levels. DNP graduates as leaders in practice arena provide a critical interface between practice, research, and policy. Preparing graduates with the essential competencies to assume a leadership role in the development of health policy requires that students have opportunities to contrast the major contextual factors and policy triggers that influence health policy-making at the various levels.

The DNP program prepares the graduate to:

  1. Critically analyze health policy proposals, health policies, and related issues from the perspective of consumers, nursing, other health professions, and other stakeholders in policy and public forums.
  2. Demonstrate leadership in the development and implementation of institutional, local, state, federal, and/or international health policy.
  3. Influence policy makers through active participation on committees, boards, or task forces at the institutional, local, state, regional, national, and/or international levels to improve health care delivery and outcomes.
  4. Educate others, including policy makers at all levels, regarding nursing, health policy, and patient care outcomes.
  5. Advocate for the nursing profession within the policy and healthcare communities.
  6. Develop, evaluate, and provide leadership for health care policy that shapes health care financing, regulation, and delivery.
  7. Advocate for social justice, equity, and ethical policies within all healthcare arenas.

Essential VI: Interprofessional Collaboration for Improving Patient and Population Health Outcomes1

Today's complex, multi-tiered health care environment depends on the contributions of highly skilled and knowledgeable individuals from multiple professions. In order to accomplish the IOM mandate for safe, timely, effective, efficient, equitable, and patient-centered care in a complex environment, healthcare professionals must function as highly collaborative teams (AACN, 2004; IOM, 2003; O'Neil, 1998). DNP members of these teams have advanced preparation in the interprofessional dimension of health care that enable them to facilitate collaborative team functioning and overcome impediments to interprofessional practice. Because effective interprofessional teams function in a highly collaborative fashion and are fluid depending upon the patients' needs, leadership of high performance teams changes. Therefore, DNP graduates have preparation in methods of effective team leadership and are prepared to play a central role in establishing interprofessional teams, participating in the work of the team, and assuming leadership of the team when appropriate.

The DNP program prepares the graduate to:

  1. Employ effective communication and collaborative skills in the development and implementation of practice models, peer review, practice guidelines, health policy, standards of care, and/or other scholarly products.
  2. Lead interprofessional teams in the analysis of complex practice and organizational issues.
  3. Employ consultative and leadership skills with interprofessional and interprofessional teams to create change in healthcare and complex healthcare delivery systems.

Essential VII: Clinical Prevention and Population Health for Improving the Nation's Health

Clinical prevention is defined as health promotion and risk reduction/illness prevention for individuals and families. Population health is defined to include aggregate, community, environmental/occupational, and cultural/socioeconomic dimensions of health. Aggregates are groups of individuals defined by a shared characteristic such as gender, diagnosis, or age. These framing definitions are endorsed by representatives of multiple disciplines including nursing (Allan et al., 2004).

The implementation of clinical prevention and population health activities is central to achieving the national goal of improving the health status of the population of the United States. Unhealthy lifestyle behaviors account for over 50 percent of preventable deaths in the U.S., yet prevention interventions are underutilized in health care settings. In an effort to address this national goal, Health People 2010 supported the transformation of clinical education by creating an objective to increase the proportion of schools of medicine, nursing, and other health professionals that have a basic curriculum that includes the core competencies in health promotion and disease prevention (Allan et al., 2004; USHHS, 2000). DNP graduates engage in leadership to integrate and institutionalize evidence-based clinical prevention and population health services for individuals, aggregates, and populations.

Consistent with these national calls for action and with the longstanding focus on health promotion and disease prevention in nursing curricula and roles, the DNP graduate has a foundation in clinical prevention and population health. This foundation will enable DNP graduates to analyze epidemiological, biostatistical, occupational, and environmental data in the development, implementation, and evaluation of clinical prevention and population health. Current concepts of public health, health promotion evidence-based recommendations, determinates of health, environmental/occupational health, and cultural diversity and sensitivity guide the practice of DNP graduates. In addition, emerging knowledge regarding infectious diseases, emergency/disaster preparedness, and intervention frame DNP graduates' knowledge of clinical prevention and population health.

The DNP program prepares the graduate to:

  1. Analyze epidemiological, biostatistical, environmental, and other appropriate scientific data related to individual, aggregate, and population health.
  2. Synthesize concepts, including psychosocial dimensions and cultural diversity related to clinical prevention and population health in developing, implementing and evaluating interventions to address health promotion/disease prevention efforts, improve health status/access patterns, and/or address gaps in care of individuals, aggregates, or populations.
  3. Evaluate care delivery models and/or strategies using concepts related to community, environmental and occupational health, and cultural and socioeconomic dimensions of health.

Essential VIII: Advanced Nursing Practice

The increased knowledge and sophistication of healthcare has resulted in the growth of specialization in nursing in order to ensure competence in these highly complex areas of practice. The reality of the growth of specialization in nursing practice is that no individual can master all advanced roles and the requisite knowledge for enacting these roles. DNP programs provide preparation within distinct specialties that require expertise, advanced knowledge, and mastery in one area of nursing practice. A DNP graduate is prepared to practice in an area of specialization within the larger domain of nursing. Indeed, this distinctive specialization is a hallmark of the DNP.

Essential VIII specifies the foundational practice competencies that cut across specialties and are seen as requisite for DNP practice. All DNP graduates are expected to demonstrate refined assessment skills and base practice on the application of biophysical, psychosocial, behavioral, sociopolitical, cultural, economic, and nursing science as appropriate in their area of specialization.

DNP programs provide learning experiences that are based in a variety of patient care settings, such as hospitals, long-term care settings, home health, and/or community settings. These learning experiences should be integrated throughout the DNP program of study to provide additional practice experiences beyond those acquired in a baccalaureate nursing program. These experiential opportunities should be sufficient to inform practice decisions and understand the patient care consequences of decisions. Because a variety of differential roles and positions may be held by the DNP graduate, role preparation for specialty nursing practice, including legal and regulatory issues, is part of every DNP program's curricula.

The DNP program prepares the graduate to:

  1. Conduct a comprehensive and systematic assessment of health and illness parameters in complex situations, incorporating diverse and culturally sensitive approaches.
  2. Design, implement, and evaluate therapeutic interventions based on nursing science and other sciences.
  3. Develop and sustain therapeutic relationships and partnerships with patients (individual, family or group) and other professionals to facilitate optimal care and patient outcomes.
  4. Demonstrate advanced levels of clinical judgment, systems thinking, and accountability in designing, delivering, and evaluating evidence-based care to improve patient outcomes.
  5. Guide, mentor, and support other nurses to achieve excellence in nursing practice.
  6. Educate and guide individuals and groups through complex health and situational transitions.
  7. Use conceptual and analytical skills in evaluating the links among practice, organizational, population, fiscal, and policy issues.

1The use of the term "collaboration" is not meant to imply any legal or regulatory requirements or implications.