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On a word document, using APA 7 format, scholarly references no older than 5 yhears old.
Select a Middle range theory
· Identify the major concepts, model, and philosophical underpinning
· Evaluated the heuristic value of the theory
relate it with the investigation projectt: determine the effectiveness of antineuropathic such as pregabalin and gabapentin as first line treatment on lumbar radiculopathy instead opioids.
PLEASE READ and FOLLOW THE RUBRIC AND THE GUIDELINES UPLOADED
remember to add the DNP essential related to the investigation
1
Running Head: AN ANALYSIS OF BENNER’S NOVICE TO EXPERT THEORY
An Analysis of Benner’s Novice to Expert theory
Karen Perez
The Evolution of Nursing Practice & Application of Theory in Nursing Practice
University of Miami
NUR 654
Dr. Cianelli
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BENNER’S NOVICE TO EXPERT
An Evaluation of Benner’s Work
Patricia Benner a nursing theorist, lecturer, researcher and the author of nine books was
born in August, 1942 in Hampton, Virginia (Sitzman & Eichelberger, 2011). Benner received
both her associates and baccalaureate of art in nursing from Pasadena City College (Sitzman &
Eichelberger, 2011). She matriculate to the University of California San Francisco (UCSF) in
1970 for her master’s degree with a focus on medical surgical nursing, and then completed her
PhD in stress, coping, and health at University of California Berkeley in 1982 (Sitzman &
Eichelberger, 2011). Benner worked at UCSF School of nursing in the capacity of researcher
and professor in the physiological and social behavioral science department. Benner was
mentored by Virginia Henderson who greatly influenced her thinking in nursing (Brykczynski,
2010a). In 1984, Benner published her first book, From Novice to Expert, which was influenced
by a project she worked on which was funded by a federal grant titled: Achieving Methods of
Extraprofessional Consensus, Assessment and Evaluation Project (Altmann, 2007) and has
received several awards and honors for her work in nursing (Brykczynski, 2010a).
Philosophical underpinning
Stuart Dreyfus and Hubert Dreyfus are brothers who are both professors at UCSF
(Sitzman & Eichelberger, 2011). Stuart Dreyfus a system analyst and mathematician and Hubert
Dreyfus a philosopher created their model of skill acquisition grounded on the study of chess
players and airline pilots (Benner, 2001). Their theory was that students’ skill formation and
acquisition goes through five stages of proficiency: novice, advanced beginner, competent,
proficient, and expert (Benner, 2004). Benner Adapted and applied Dreyfus & Dreyfus’ model
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BENNER’S NOVICE TO EXPERT
to nursing. Benner outlined the model of skill and learning in clinical nursing practice in her
theory Novice to Expert which stated that nurses develop skills and knowledge overtime, through
sound education and experience (Sitzman & Eichelberger, 2011). In 1989, Benner worked with
Judith Wrubel in the expansion of her model to include caring with the stages of skill acquisition
(Benner, 1995). The newer model was further influenced by the work of Mauirce Merleau-Ponty
and Martin Heidegger, two philosophers (Benner, 2001). Despite the many criticism, this was
one of the first theories that described the learning process in nursing.
Assumption
Benner has nine assumptions which were based on the individuals who influenced her
work. The first assumption is that theory is derived from practice (Benner, 2001); which means
that knowledge development (know-how and know that) is vastly dependent on practical
knowledge in applied discipline (Benner, 2001). Kuhn & Polanyi (1970 & 1958) called the
“know how” practical and the “know that” theoretical. The second assumption is that human
knowledge is more than rational calculation; which implies that intuition, which is not easily
observed or explained (Johns, 1995), occurs when an individual, especially an expert nurse no
longer relies on premeditated rational but instead uses intuition that is developed through
reflective practice (Benner, 2001). The third assumption is that theory surrounds the issues and
directs the nurse in what questions to ask and where to seek the answers (Benner, 2001). This
assumption indicates that in order for practitioner to practice effectively with positive outcome,
theory is needed to direct their action (Benner, 2001). The fourth assumption is that nursing
practice functions in a systemic way and view the client and situations in a holistic way (Benner,
2001). This infers that the nursing profession looks at the client as a whole and not in systems
while using a systemic approach (Benner, 2001). The fifth assumption is that caring is the basis
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BENNER’S NOVICE TO EXPERT
of altruism which is to say in order for an individual to genuinely have concern and welfare for
others, caring is the foundation. The sixth assumption stated that caring is an important requisite
for all surviving, meaning that in order for both the nurse and client to cope in every situation,
caring is needed. The seventh assumption stated that caring and interdependence are the ultimate
goals of adult growth and change, which implies that both the adult client and the nurse are
mutually dependent on each other during the client-nurse relationship, while both care for self
and each other (Benner, 2001). The eighth assumption is that concern is essential for the nurse to
be situated, which means that caring is paramount for the nurse to be effective in his/ her role.
The final assumption proposed that irrespective of the stage, practitioners cannot practice beyond
his/her experience (Benner, 2001).
Metaparadigm / Major Concepts
Benner’s theory, like most theories, identify four metaparadigm: nursing, person, health
which she called well-being, and environment which that called situation. Nursing, she defined
as a supporting network which includes the emotions between the client and the nurse (Benner,
2001). She viewed nursing practice as the caring and studying of the lived experience of illness,
disease, and health with nurses possessing the power to influence the lived experience (Benner,
2001). She defined person as a self-evolving being; this is to say, that the person did not enter
the world with all the characteristic, neither tangible nor intangible, that they will need for the
rest of their lives, but is shaped by their experiences in life. She used the concept well-being
instead of health because the term is more phenomenological (Benner, 2001). She defined well-
being as the congruence between an individual’s potential and the individual’s actual practice as
it is based on caring and feeling cared for (Benner, 2001). She also used the concept situation
rather than environment because it is more applicable to nursing, and the term environment is too
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BENNER’S NOVICE TO EXPERT
broad (Benner, 2001). She defined situation as a phenomena that is experienced by everyone
and places a vital role in how an individual views the world (Benner, 2001).
The Model
Benner adapted Dreyfus & Dreyfus’ five levels of skill acquisition, novice, advanced
beginner, competent, proficient, and expert, and apply to nursing with progression from novice
to expert not guaranteed (Benner, 1984). Benner (2001) described novice as a nurse who has no
experience of the situation and learn features of task that can be recognized without situational
experience. New clinical situation is needed for the novice nurse to develop skills and requires
objectives and measurable parameters to care for client (Benner, 2004). The novice nurse is
described as a newly graduated nurse, or a nurse who is taking care of clients in an unfamiliar
situation and is inflexible and rely on strict rules to guide his/her practice; for this reason
objectives and measurable parameters are needed (Dale, Drew, Dimmitt, Hildebrandt, Hittle,
Tielsch-Goddard, 2013). Their approach to the task at hand is “tell me what I need to do and I
will do it” (Benner 2001). It is evident that in order for the novice to move to the next level, an
opportunity must exist for the nurse to gain experience.
In contrast to the novice, the advanced beginner has gained some experience which enables
him/her to identify the meaning of events that are reoccurring (Dreyfus & Dreyfus, 1980). Even
though they have gained some experience they are unable to prioritize task (Benner, 2001). For
example, if an advanced beginner nurse has a list of tasks to be done, he/she will not change the
order of task even if something else is a priority (Benner, 2001).
The competent nurse has approximately two to three years of experience in which he/she
starts to view plan of action in terms of long-range goals with plans made consciously enabling
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BENNER’S NOVICE TO EXPERT
nurse to prioritize (Benner, 2001). While planning helps the competent nurse to be organized
and effective, he/she still lacks speed and flexibility (Benner, 2001).
The proficient nurse anticipates situations as a whole instead of fragments, and gained
experience from past situations (Benner, 2001). They can recognize when a plan needs to be
revamped due to unexpected or expected reasons and uses maxims as a guide (Benner, 2001).
On the other hand, an expert nurse is a nurse with many years of experience and has an
intuitive handle on situations which come from experience and knowledge gained over a period
of time (Benner, 2001). This nurse has a deep connection and understanding of the situation;
he/she no longer relies on analytic principle and flexible (Benner, 2001).
Heuristic Value of the Theory
Benner’s model From Novice to Expert is widely used in nursing practice, research,
education and administration (Altmann, 2007). The Institute of Medicine report in 2004,
indicated the important role nurses play in patient safety. This report was instrumental to the
American Nursing Association to conduct a study to see the attributes in nurses that affected
patient safety. Using Benner’s models they were able to identify nurses with different levels of
experience and assess their patient outcome. The findings indicated that nurses’ years of
experience influence the quality of care delivered (Aiken, Havens, & Slone, 2009). Benner’s
model is widely used in hospitals, especially hospitals with residence programs, to track the
progress of the new graduate nurse and to assign mentors/preceptors (Benner, 2001). Benner’s
model is beneficial to mentoring programs because it shows how novice nurses can benefit
greatly from proficient and expert nurses (Benner, 2001). The model is not only used to identify
and correct issues related to the nursing practice, but it is also used to identify employees in most
professions for growth, and as a guideline for career knowledge development in many settings
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BENNER’S NOVICE TO EXPERT
(Benner, 2001). Due to the applicability of the model, it has been used in academic settings
other than nursing such as kindergarten through college. According to Pesata (1994) the
dynamics of school nursing has evolved since the enactment of the Education for all Handicap
Children’s Act. This change required advanced nurse practitioners to be skilled and
knowledgeable in this setting. To be effective, Benner’s model of Expert practice was used to
promote optimal function in children with multiple handicaps (Pesata, 1994).
Critic of Model
Even though Benner’s theory is being widely used, her theory has been critiqued by
many. Nursing practice has been formed and studied from a sociological view (Benner, 2001),
despite Benner’ acknowledgement of the vital role sociology plays in the nursing practice, she
failed to recognize the dependence of this in her model (Thompson 1990; Purkis 1994; & Rudge
1992). Altmann (2007) highlighted the need for an operational definition of expertise and
intuition which will allow the concepts to be tested and measured. Benner views expertise and
intuition as phenomenological; this view makes the concept difficult to measure and test (Effken,
2001). English (2003) pointed out the difficulty of measuring the continuum of the stages,
because no explanation is given of what phenomena takes place for the transition from one stage
to the next which makes creating a guide to assist nurses to become experts challenging.
In Benner’s original research she had 21 nurse preceptors and 21 new graduate nurses, 51
experienced nurses, 11 newly graduated nurses, and 5 senior nursing students (Benner, 1984.
She collected her data by interviews with narrative accounts of situation and by observation of
behaviors in clinical settings (Benner, 1984) and according to Allen & Cloyes (2005), these
interviews were conducted with critical care nurses in small groups or individuals who were
chosen based on experience and / or managers’ evaluations. This left critics to question the
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BENNER’S NOVICE TO EXPERT
methodological process claiming that problems existed with sampling which indicated a bias
toward the positive, and the model was built on qualitative research instead of quantitative,
further opening the model to criticism. (Altmann, 2007). The question of credibility and validity
arise because the narrative data given by the participants and the interpretation of the data by the
researchers were subjective (Nelson & McGillion, 2004). Another issue was that no background
information was given about one of her researchers in one interpretation of the data which could
possible affect the interpretation of the data collected (Atlmann, 2007).
Analysis
The Novice to Expert theory provides a useful frame work which has been adapted by
schools of nursing, hospitals, social agencies, and continuing education programs. It is also used
for the foundation of preceptor programs. Even though the frame work is used in many different
settings, it is not beneficial as a curriculum model for pre-registration nurse education (Atlmann,
2007). While Benner provided theoretical definitions for all major concepts, there were no
operational definition necessary for empirical measurement (Atlmann, 2007). Even though
Benner’s model is simple, brief, and general, it is situational specific (Atlmann, 2007). The five
stages of skill acquisition is easy and simply to follow and apply except for the challenges that
are encountered in identifying what prompt the transitions through the stages (Cash, 1995).
While the theory is useful in the different professions, it is not based on empirical methodology
and is often critized for not being developed from quantitative research (Cash, 1995)
Conclusion
To conclude, Benner’s novice to expert theory gave tremendous insight in how
individuals acquire skills and how it can be nurtured. Even though the critics stated that the
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BENNER’S NOVICE TO EXPERT
theory is not beneficial to pre-registering nursing curriculum, it gives nursing educators the
understanding of the transition of nursing students. This understanding will better equip nursing
educators to design more effective teaching and learning strategies. The theory adds knowledge
and raised questions in the nursing practice which will better help the profession not only to
guide our nursing students, but to help nurses in terms of impacting direct care or to aid in
personal development and growth.
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BENNER’S NOVICE TO EXPERT
References
Aiken, L., Haven, D. & Sloane, D. (2009). The magnet nursing services recognition program: a
comparison of two group of magnet hospital. Journal of Advanced Nursing, 39(7/8), s5-
s14
Altmann. T. K., (2007). An evaluation of the seminal work of Patricia Benner: Theory or
Philosophy? Contemporary Nurse, 25(1), 114-123
Allen, D. & Cloyes, K. (2005). The language of experience in nursing research. Nursing Inquiry
(12), 98-105
Benner, P. A. (1984). From Novice to Expert: Excellence and power in clinical nursing practice.
Menlo Park, CA: Addison-Wesley
Benner, P. A. (1995). A response by P. Benner to K. Cash, “Benner and expertise in Nursing: a
critique”. International Journal of Nursing Studies, 32(6), 527-527
Benner, P.A. (2004). Using the Dreyfus model of skill acquisition to describe interpret skill
acquisition and clinical judgment in nursing practice and education. Bulletin of Science,
Technology & Society, 24(3), 188-199.
Benner, P. A. (2001). From Novice to Expert: Excellence and power in clinical nursing practice.
Upper Saddle River, New Jersey: Prentice Hall Health
Brykczynsk. K. A. (2010a). Nursing theorist and their work. (7thth ed.). Maryland Heights, Mo:
Mosby Elsevier.
Brykczynsk. K. A. (2010b). Benner’s philosophy in nursing practice, In M. R. Alligood (4th ed.),
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BENNER’S NOVICE TO EXPERT
Nursing Theory: Utilization and application (pp. 137-159). Heights, Mo: Mosby Elsevier
Cash, K. (1995). Benner and expertise in nursing: a critique. International Journal Nursing
Study, 32 (6), 527-534
Dale, J. C., Drews, B., Dimmitt, P., Hildebrandt, E., Hittle, K., & Tielsch-Goddard, A.
(2013). Novice to Expert: the evolution of an advanced practice evaluation Tool. Journal
of Pediatric Health Care, 27(3), 195-201
Dreyfus, S. E. & Dreyfus, H. L. (1980). A five-stage model of mental activities involved in
direct skill acquisition. (Rep. No. ORC-80-2). University of California, Berkeley,
Operations Research Center.
Effken, J. A. (2011). Informational basis for expert intuition. Journal of Advance Nursing,
(34) 246-255
English I. (1993), Intuition a function of the expert nurse: A critique of Benner’s novice to expert
model. Journal of Advanced Nursing 18, 387-393
John, C. (1995). The value of reflective practice for nursing. Journal of Clinical Nursing, 4,
23-30.
Kuhn T. S. (1970). The structure of scientific revolutions. Chicago: University of Chicago Press
Nelson, S. & McGillion (2004). Expertise or performance? Questioning the rhetoric of
contemporary narrative use in nursing. Journal of Advanced Nursing, (47), pp. 631-638
Pesata V. L. (1994). Applying Benner’s model to school of multiple handicapped children.
Clinical nurse special, 8 (5),
Polanyi M. (1958). Personal knowledge: Towards a post critical philosophy. Chicago:
University of Chicago press.
Purkis, M. E. (1994). Entering the field: Intrusions of the social and its exclusion from
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BENNER’S NOVICE TO EXPERT
studies of nursing practice. International Journal of Nursing Studies. (31), pp. 315-336
Rudge, T. (1992). Reflections of Benner: A critical Perspective. Contemporary Nursing (1),
84-88
Sitzman, K. L., & Eichelberger, L. W. (2011). Understanding the work of nurse theorists: A
creative beginning. (2nd Ed.). Subbury, MA: Jones and Bartlett.
Thompson, J. L. (1990). Hermeneutic inquiry in Moody E. (Ed.) Advancing Nursing Science
through Research (2), 223-280
Doctor of Nursing Practice Program
DNP 7000
Middle Range Theory Scholarly Paper
Evolution of Nursing Practice Application of Theory in Nursing
February 28, 2020
Middle Range Theory Scholarly Paper
Purpose
This is an individual assignment. The purpose of this paper is to analysis and evaluates a
middle range theory. The paper should include the major concepts, the model, and the
philosophical underpinnings. Evaluate the heuristic value of the
theory
along with its use in
practice/research. You can use the guideline that is below to write your paper. This
assignment should be maximum 15 pages (excluding references, tables, pictures and
graphics), double spaced, Times Roman, 12 font. Submit your assignment with a title page,
abstract and reference page using APA 6th Edition. References must include at least 15
journals. Select a different Middle Range Theory that the one that you presented in class
.
Guideline
Topic Point Value
Introduction 10%
Philosophical Underpinnings 10%
Main Concepts of the Theory 15%
The Model 15%
Heuristic Value of the Theory 10%
Analysis 20%
Conclusion 10%
References 10%
Doctor of Nursing Practice Program
DNP 7000
Middle Range Theory Scholarly Paper
Evolution of Nursing Practice Application of Theory in Nursing
February 28, 2020
DIRECTIONS AND GRADING CRITERIA
Category Points % Description
Introduction
10 points
10 10 Introduces the purpose of the assignment. Rationale is well presented
and purpose fully developed.
Philosophical
Underpinnings
10 points
10 10 Include a description of the philosophical underpinning of the Middle
Range Theory selected.
Main Concepts
of
the
Theory
1
5 points
15 15 Provide a complete description of the main concepts of the theory.
The Model
15 points
15 15 Provide a description of the theoretical model and its application.
Heuristic Value
of
the
Theory
10 points
10 10 Describe the Heuristic value of the selected theory.
Analysis
20 points
20 20 Provide an analysis of the theory application.
Conclusion
10 points
10 10 Provide a fully developed conclusion summarizing the content of the
paper.
Reference /
APA
10 10 Provide at least six articles within the last 5 years. Paper follows APA format
Total: 100 100 A quality essay will meet or exceed all of the above
requirements.
Doctor of Nursing Practice Program
DNP 7000
Middle Range Theory Scholarly Paper
Evolution of Nursing Practice Application of Theory in Nursing
February 28, 2020
GRADING RUBRIC
Assignment
Criteria
Meets Criteria Partially Meets Criteria Does Not Meet Criteria
Introduction
10 points
Excellent introduction
with information on the
theorist and theory (DOB,
education, and creation of
theory).
10 points
Introduction about the
theory and theorist is
sufficient (DOB,
education, and creation of
theory).
.
6 points
Introduction about the theory
and theorist is minimal.
4 points
Introduction is general with
no information about the
theorist and theory
0 point
Philosophical
Underpinnings
10 points
Excellent information on
the history and making of
the
theory.
10 points
Good information on the
history and making of the
theory.
6 points
Minimal information on the
history and making of the
theory.
4 points
Unacceptable / general
information on the history
and making of
the theory.
0 point
Doctor of Nursing Practice Program
DNP 7000
Middle Range Theory Scholarly Paper
Evolution of Nursing Practice Application of Theory in Nursing
February 28, 2020
Main Concepts of
the Theory
15 points
Clear and excellent
information on the main
Concepts of the Theory
15 points
Good information on the
main Concepts of the
Theory
10 points
Minimal information on the
main Concepts of the Theory
5 points
General or little
information
on the main Concepts of the
Theory
0 point
The Model
15 points
Excellent information on
the description the
representation and used of
the theory.
15 points
Sufficient information on
the description the
representation and used of
the theory.
10 points
Minimal information on the
description, representation
and used of the theory.
5 points
General or little information
on the description the
representation and used of
the theory.
0 point
Heuristic Value of
the Theory
10 points
Excellent information on
Heuristic Value of the
Theory
10 points
Good information on
Heuristic Value of the
Theory
7 points
Minimal information on
Heuristic Value of the Theory
4 points
little or no information on
Heuristic Value of the
Theory
0 point
Analysis
20 points
Excellent information on
the
empirical adequacy and
critique of the theory
Good information
empirical adequacy and
critique of the theory
Minimal information on
empirical adequacy and
critique of the theory
little or no empirical
adequacy and critique of the
theory
Doctor of Nursing Practice Program
DNP 7000
Middle Range Theory Scholarly Paper
Evolution of Nursing Practice Application of Theory in Nursing
February 28, 2020
20 points 15 points 8 points 0 point
Conclusion
10 points
Excellent conclusion with
summary of the paper that
contains no new
information
10 points
Provide a fully developed
conclusion summarizing the
content of the paper.
8 points
Provide a somewhat developed
conclusion summarizing the
content of the paper.
6 points
Does not provide fully
developed conclusion
summarizing the content of the
paper.
0 point
Reference /
APA
10 points
Reference page and in text
citation are completed
according to the APA
format. Paper contains 6
articles that were published
within the last 5
years.
10 points
Reference page and in text
citation are most completed
according to the APA
format. Paper contains 5
articles that were published
within the last 5 years.
8 points
Reference page and in text
citation are somewhat
completed according to the
APA format. Paper contains 3
articles that were published
within the last 5 years.
6 points
Reference page and in text
citation are not completed
according to the APA
format. Paper contains less
than 3 articles that were
published within the last 10
years.
0 points
Total Points Possible = 100 points
Theory of Chronic Sorrow
Eakes, Burke, Hainsworth
Georgene Gaskill Eakes
Born: New Bern, NC
1980: MSN @ University of NC at Greensboro.
1998: PhD from NC State University
1970: MVA- catalyst for chronic sorrow theory.
Burke & Hainsworth
Mary Lermann Burke
Born in Sandusky, OH
MSN from Boston University
PhD from Boston University
Catalyst in Theory Development: Interest in child development.
Worked with spina- bifida children and their mothers.
Developed the Burke Chronic Sorrow questionnaire.
Margaret Hainswroth
Born: Ontario, Canada
1974: MSN Boston College.
1986: PhD in Education Administration at University of Connecticut.
Catalyst: Worked in Mental Health, public health and led a women’s support group for women with MS.
Nursing Consortium for Research on Chronic Sorrow (NCRCS)
Nursing theorists began studying chronic sorrow in the 1980s after they had observed it in their nursing practice.
In 1989, nursing theorists Eakes, Burke, Hainsworth and Carolyn Lindgren established the Nursing Consortium for Research on Chronic Sorrow (NCRCS) to jointly study chronic sorrow.
Expanded the relevance of the concept to individuals experiencing a variety of loss situations, as well as to their family caregivers.
Eakes, Burke & Hainsworth, 1992
4
Definition of Chronic Sorrow
A periodic recurrence of permanent, pervasive sadness or other grief- related feelings associated with ongoing disparity resulting from a loss experience.
A normal response to an ongoing loss situation.
Eakes, Burke & Hainsworth, 1998
Defining Characteristics of Chronic Sorrow
A perception of sadness or sorrow over time in a situation with no predictable end.
Sadness or sorrow that is cyclic or recurrent.
Sadness or sorrow that is triggered internally or externally and brings to mind a person’s losses, disappointments, or fears.
Sadness or sorrow that is progressive and can intensity.
Eakes, Burke & Hainsworth, 1998
History of the Theory
First documented as a middle range theory in 1998.
Explains how individuals may respond to both ongoing and single- loss events.
Created to characterize the recurring episodes of grief experienced by parents of children with disabilities (Olshansky, 1962).
Olshansky, 1962
Use and Development
Useful for analyzing individual responses of people experiencing ongoing disparity due to chronic illness, caregiving responsibilities, loss of the “perfect” child, or bereavement.
The theory was developed using concept analysis, critical review of research, and validation in 10 qualitative studies of various loss situations (196 interviews reviewed).
Inductively derived and validated through a series of 10 qualitative studies conducted by members of the Nursing Consortium for Research on Chronic Sorrow (NCRCS) and a critical review of existing research.
Provides a framework for understanding the reactions of individuals to various loss situations.
Offers a new way of viewing the experience of bereavement.
Eakes, Burke & Hainsworth, 1998
Use and Development
Theory is useful for analyzing individual responses of people experiencing ongoing disparity due to chronic illness, caregiving responsibilities, loss of the “perfect” child, or bereavement.
Nurses need to view chronic sorrow as a normal response to loss and, when it is triggered, provide support by fostering positive coping strategies and assuming roles that increase comfort .
With an understanding of chronic sorrow, nurses can plan interventions that recognize it as a normal reaction, promote healthy adaptation, and provide empathetic support.
Eakes, Burke & Hainsworth, 1998
Theoretical Assertions
Sorrow occurs to everyone at some point in life.
Chronic sorrow is a normal response to the ongoing disparity or void create by significant loss.
Different degrees of sorrow can occur over time.
Human response: natural and not pathological.
Cycles: Chronic sorrow occurs in periodic cycles.
Triggers: Different events that spark the feeling of sorrow.
Coping Strategies: Humans have an innate ability to cope.
Health Care Intervention: Nurses should provide assistance.
Ideal and Reality: Humans see a disconnect between the two.
Eakes, Burke & Hainsworth, 1998
Theoretical Model
Purpose: Useful for analyzing individual response of people experiencing ongoing disparity due to chronic illness, caregiving responsibilities, loss of the “perfect” child, or bereavement.
Provides alternative way of viewing the experience of grief.
Eakes, Burke & Hainsworth, 1998
“The pain will never completely go away, but like anything else, you just learn to live with it. You learn how to live with an amputated limb. You learn how to live with a broken heart”.
-Mary Lermann Burke
Burke, 1994
Antecedents
#1: A loss with no predictable end.
Birth of a disabled child
Diagnosis of chronic illness
Death of a loved one
#2: Ongoing disparity resulting from the loss.
A gap exists between the desired and the actual reality.
Lack of closure associated with ongoing disparity sets the stage for chronic sorrow.
Eakes, Burke & Hainsworth, 1998
Theoretical model
Eakes, Burke & Hainsworth, 1998
Concepts
Chronic Sorrow
Periodic recurrence of permanent, pervasive sadness or other grief related feelings associated with a significant loss
Disparity
The difference between the ideal and the real situation due to some type of loss.
Antecedents
Chronic illness (patient or caregiver)
A recognized negative disparity between the past and the present
The occurrence of events that bring the disparity into focus.
Eakes, Burke & Hainsworth, 1998
Concepts
Loss
Primary antecedent that must occur before the onset of sorrow.
Trigger events or milestones
Circumstances, situations, conditions that bring the negative disparity resulting from loss experience into focus.
Exacerbates the experience of disparity.
Effective Internal management
Action oriented strategies that increase feelings of control.
Used to cope with the recurrence of grief related feelings of chronic sorrow.
Cognitive “can do” and interpersonal (talking with someone close or, support group).
External management
Healthcare professionals (external management methods- therapy).
Based on premise that chronic sorrow is a normal response to a significant loss situation.
Eakes, Burke & Hainsworth, 1998
Concepts
Management methods (Internal/External)
Coping strategies used by a person with chronic sorrow (internal) and to interventions provided by professionals (external).
Internal management methods consist of individualized coping interventions initiated by the person experiencing chronic sorrow.
External management methods of coping consist of interventions provided by medical professionals to aid in effective coping.
professional counseling,
pharmaceutical interventions to treat symptoms of insomnia or anxiety if necessary,
pastoral care or spiritual support to assist with grieving,
use of therapeutic communication, and
referral services
Gordon, 2009
Other concepts
Other concepts related to the framework:
Coping – “Facing difficulties and acting to overcome them”.
Parents – “A mother or father who nurtures and raises a child” (initial focus of chronic sorrow theory).
Child – “A son or daughter, an offspring” (initial focus of chronic sorrow).
Olshansky, 1962
Meta- Paradigms/Major Assumptions
Person
Experiences sorrow in cycles and can experience periods of overwhelming sorrow.
Experience periods of normalcy and overwhelming grief in cycles.
Environment
Addresses if the person has a good social support.
Health
How well the person copes and uses coping mechanisms to deal with sorrow.
Nursing
Assessment of grief is an essential component of nursing (part of nursing assessment due to effects on wellness).
Incorporation of therapeutic communication can be beneficial to patient’s healing process.
Nurses should make provision for bereavement counseling when events trigger symptoms of chronic sorrow that can occur years after the loss.
Nurses should provide for anticipatory counseling for trigger events as well as reinforce effective internal and external coping mechanisms.
Eakes, Burke & Hainsworth, 1998
Philosophical Underpinnings
People may periodically re-experience the pervasive sadness or other grief-related feelings that occur when initially confronted with the loss.
Simon Olshansky:
Counselor to parents of handicapped children.
Introduced chronic sorrow in 1960s to describe normal pervasive physiological response in suffering of parents dealing with mentally disabled children
Encouraged professionals to recognize chronic sorrow as a natural response to a tragic situation in order to assist parents in achieving greater comfort living with and managing a child with a mental disability
Described chronic sorrow as ongoing yet periodic, as well as normal.
1980s and early 1990s- Nursing profession first introduced Olshanksky’s theory through concept analysis of Chronic sorrow.
Olshansky, 1962
Philosophical Underpinnings
Teel (Concept analysis):
Examined theories of time-bound grief and of chronic grief or mourning.
Teel used these concepts in adapting Olshansky’s definition of chronic sorrow for nurses.
Prolonged chronic grief or mourning results when adaptation is not made; it is considered an abnormal response.
Contrasted with Olshansky model of grief.
Teel defined chronic sorrow as: a pervasive psychic pain and sadness, stimulated by certain trigger events, which follows loss of a relationship of attachment.
Teel also described chronic sorrow as being precipitated by a permanent loss of a personal attachment that may ne ongoing with sadness of varied intensity that recurs for the lifetime of the disabled person.
Teel, 1991
Philosophical Underpinnings
Lazarus and Folkman
Model of Stress and Adaptation
Transaction (interaction) occurs between a person & the environment
Stress results from an imbalance between (a) demands & (b) resources.
We become stressed when demands (pressure) exceeds our resources (our ability to cope & mediate stress).
Freud
Grief work has it’s origins in Sigmund Freud’s Mourning and Melancholia.
Mourning is the “normal” response to death.
In grief the world becomes poor and empty.
A normal response of mourning entails working through the grief.
Lazarrus & Folkman, 1984, Freud, 1917
Newman Typology
Fawcett, 1999
World view
Fawcett, 1999
Analysis: Heuristic value
Parsimonious:
Presented in a clear and concise manner.
Well accepted by the nursing profession.
Used in many different specialties of the nursing profession.
Provides a framework for understanding the reactions of individuals to loss
Logically developed from 10 qualitative studies conducted by the Consortium for Research on Chronic Sorrow.
Theory aids in the understanding of the loss experience.
Authors are able to draw conclusions and make arguments that are well supported by clinical and research data.
Conceptualization of the model is easily displayed in the theoretical model.
Eakes, 1998, 2004
Use of the Theory
Analysis: Empirical Adequacy
Explains chronic sorrow.
Future research: identification of other conditions that commonly lead to chronic sorrow.
Research could generate hypotheses based on the theoretical model.
Theoretical model lends itself to research on effectiveness of interventions for caregivers and patients.
Can be used to determine what conditions are more likely to trigger an exacerbation of chronic sorrow and begin chronic sorrow experience (beneficial for nursing).
Easily applied in clinical settings.
Analysis: Critique of Theory
Does not address why some individuals do not experience sorrow.
Does not consistently demonstrated progressivity of the emotions associated with chronic sorrow
Should examine whether there are predictors of those who will not experience chronic sorrow.
Loss
That 2 year old toddler was actually 2 weeks away from turning two.
She died on March 28, 1998.
She was an amazing and beautiful little girl filled with adventure and filled with so much love.
She left behind her mother, father, 18 year old sister and 6 year old brother
Loss
41 year old found floating in Markham Park on November 15th 2005 (after Hurricane Wilma).
Woman found attached to a road bike
Woman reported missing by her husband on November 14th after he came home from work to find her keys, jewelry, car and everything she needed for work in the home but she was not there.
Conclusion
Chronic sorrow has been shown to explain the experience of people across the lifespan who encounter ongoing disparity because of significant loss. Nurses need to view chronic sorrow as a normal response to loss and, when it is triggered, provide support by fostering positive coping strategies and assuming roles that increase comfort (Eakes, 2007).
Appropriate for middle range theory because it has a scope that is limited to the explanation of a single phenomena, that of a response to loss.
References
Abbate, G. (2014). Theory of chronic sorry
Burke, M. L. (1989). Chronic sorrow in mothers of school-age children with myelomeningocele disability. Dissertations Abstract International, 50, 2334B.
Casework, 1962, 51:190-193.
Eakes, G.G., Burke, M. I., & Hainsworth, M. A. (1998). Middle range theory of chronic sorrow. Image: Journal of Nursing Scholarship, 30(2), 179-184.
Fawcett, J. (1999). Relationship of theory and research (3rd ed.). Philadelphia: F.A. Davis.
Hainsworth, M. A., Eakes, G. G., & Burke, M. L. (1994). Coping with chronic sorrow. Issues in Mental Health Nursing, 15, 59-66.
References
Lazarus, R.S., & Folkman, S. (1984). Stress, Appraisal and Coping. New York: Springer Publishing Company.
Olshansky, S. (1962). Chronic sorrow: A response to having a mentally defective child. Social Casework, 43(4), 190-193.
Peterson, S. J., Bredow, T.S. (2009). Middle Range Theories: Application to Nursing Research. Philadelphia, PA: Lippincott Williams & Wilkins.
Teel, C.S. (1991). Chronic Sorrow: analysis of the concept. Journal of Advanced Nursing 16, 13111-1319. Retrieved November 2013, from EBSCO database.
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1
The Essentials of Doctoral Education
for Advanced Nursing Practice
October 2006
TABLE OF CONTENTS
Page
Introduction
Background 3
Comparison Between Research-Focused and Practice-Focused
Doctoral Education 3
AACN Task Force on the Practice Doctorate in Nursing 4
Context of Graduate Education in Nursing 5
Relationships of Master’s, Practice Doctorate, and Research
Doctorate Programs 6
DNP Graduates and Academic Roles 7
The Essentials of Doctoral Education for Advanced Nursing Practice 8
I. Scientific Underpinnings for Practice 8
II. Organizational and Systems Leadership for Quality
Improvement and Systems Thinking 9
III. Clinical Scholarship and Analytical Methods
for Evidence-Based Practice 11
IV. Information Systems/Technology and Patient Care Technology
for the Improvement and Transformation of Health Care 12
V. Health Care Policy for Advocacy in Health Care 13
VI. Interprofessional Collaboration for Improving Patient
and Population Health Outcomes 14
VII. Clinical Prevention and Population Health for Improving
the Nation’s Health 15
VIII. Advanced Nursing Practice 16
Incorporation of Specialty-Focused Competencies into DNP Curricula 17
Advanced Practice Nursing Focus 17
Aggregate/Systems/Organizational Focus 18
ADVANCING HIGHER EDUCATION IN NURSING
One Dupont Circle NW, Suite 530 · Washington, DC 20036 · 202-463-6930 tel · 202-785-8320 fax · www.aacn.nche.edu
2
Curricular Elements and Structure 18
Program Length 18
Practice Experiences in the Curriculum 19
Final DNP Project 19
DNP Programs in the Academic Environment: Indicators of Quality
in Doctor of Nursing Practice Programs 20
Faculty Characteristics 20
The Faculty and Practice 20
Practice Resources and Clinical Environment Resources 21
Academic Infrastructure 21
Appendix A
Advanced Health/Physical Assessment 23
Advanced Physiology and Pathophysiology 23
Advanced Pharmacology 24
Appendix B
DNP Essentials Task Force 25
References 27
3
Introduction
Background
Doctoral programs in nursing fall into two principal types: research-focused and practice-
focused. Most research-focused programs grant the Doctor of Philosophy degree (PhD),
while a small percentage offers the Doctor of Nursing Science degree (DNS, DSN, or
DNSc). Designed to prepare nurse scientists and scholars, these programs focus heavily
on scientific content and research methodology; and all require an original research
project and the completion and defense of a dissertation or linked research papers.
Practice-focused doctoral programs are designed to prepare experts in specialized
advanced nursing practice. They focus heavily on practice that is innovative and
evidence-based, reflecting the application of credible research findings. The two types of
doctoral programs differ in their goals and the competencies of their graduates. They
represent complementary, alternative approaches to the highest level of educational
preparation in nursing.
The concept of a practice doctorate in nursing is not new. However, this course of study
has evolved considerably over the 20 years since the first practice-focused nursing
doctorate, the Doctor of Nursing (ND), was initiated as an entry-level degree. Because
research- and practice-focused programs are distinctly different, the current position of
the American Association of Colleges of Nursing (AACN, 2004) [detailed in the Position
Statement on the Practice Doctorate in Nursing] is that: “The two types of doctorates,
research-focused and practice-focused, may coexist within the same education unit” and
that the practice-focused degree should be the Doctor of Nursing Practice (DNP).
Recognizing the need for consistency in the degrees required for advanced nursing
practice, all existing ND programs have transitioned to the DNP.
Comparison Between Research-Focused and Practice-Focused Doctoral Education
Research- and practice-focused doctoral programs in nursing share rigorous and
demanding expectations: a scholarly approach to the discipline, and a commitment to the
advancement of the profession. Both are terminal degrees in the discipline, one in
practice and one in research. However, there are distinct differences between the two
degree programs. For example, practice-focused programs understandably place greater
emphasis on practice, and less emphasis on theory, meta-theory, research methodology,
and statistics than is apparent in research-focused programs. Whereas all research-
focused programs require an extensive research study that is reported in a dissertation or
through the development of linked research papers, practice-focused doctoral programs
generally include integrative practice experiences and an intense practice immersion
experience. Rather than a knowledge-generating research effort, the student in a practice-
focused program generally carries out a practice application-oriented “final DNP
project,” which is an integral part of the integrative practice experience.
4
AACN Task Force on the Practice Doctorate in Nursing
The AACN Task Force to Revise Quality Indicators for Doctoral Education found that
the Indicators of Quality in Research-Focused Doctoral Programs in Nursing are
applicable to doctoral programs leading to a PhD or a DNS degree (AACN, 2001b, p. 1).
Therefore, practice-focused doctoral programs will need to be examined separately from
research-focused programs. This finding coupled with the growing interest in practice
doctorates prompted the establishment of the AACN Task Force on the Practice
Doctorate in Nursing in 2002. This task force was convened to examine trends in
practice-focused doctoral education and make recommendations about the need for and
nature of such programs in nursing. Task force members included representatives from
universities that already offered or were planning to offer the practice doctorate, from
universities that offered only the research doctorate in nursing, from a specialty
professional organization, and from nursing service administration. The task force was
charged to describe patterns in existing practice-focused doctoral programs; clarify the
purpose of the practice doctorate, particularly as differentiated from the research
doctorate; identify preferred goals, titles, and tracks; and identify and make
recommendations about key issues. Over a two-year period, this task force adopted an
inclusive approach that included: 1) securing information from multiple sources about
existing programs, trends and potential benefits of a practice doctorate; 2) providing
multiple opportunities for open discussion of related issues at AACN and other
professional meetings; and 3) subjecting draft recommendations to discussion and input
from multiple stakeholder groups. The final position statement was approved by the
AACN Board of Directors in March 2004 and subsequently adopted by the membership.
The 2004 DNP position statement calls for a transformational change in the education
required for professional nurses who will practice at the most advanced level of nursing.
The recommendation that nurses practicing at the highest level should receive doctoral
level preparation emerged from multiple factors including the expansion of scientific
knowledge required for safe nursing practice and growing concerns regarding the quality
of patient care delivery and outcomes. Practice demands associated with an increasingly
complex health care system created a mandate for reassessing the education for clinical
practice for all health professionals, including nurses.
A significant component of the work by the task force that developed the 2004 position
statement was the development of a definition that described the scope of advanced
nursing practice. Advanced nursing practice is broadly defined by AACN (2004) as:
any form of nursing intervention that influences health care outcomes for
individuals or populations, including the direct care of individual patients,
management of care for individuals and populations, administration of
nursing and health care organizations, and the development and
implementation of health policy. (p. 2)
5
Furthermore, the DNP position statement (AACN, 2004, p. 4) identifies the benefits of
practice focused doctoral programs as:
• development of needed advanced competencies for increasingly complex practice,
faculty, and leadership roles;
• enhanced knowledge to improve nursing practice and patient outcomes;
• enhanced leadership skills to strengthen practice and health care delivery;
• better match of program requirements and credits and time with the credential
earned;
• provision of an advanced educational credential for those who require advanced
practice knowledge but do not need or want a strong research focus (e.g., practice
faculty);
• enhanced ability to attract individuals to nursing from non-nursing backgrounds;
and
• increased supply of faculty for practice instruction.
As a result of the membership vote to adopt the recommendation that the nursing
profession establish the DNP as its highest practice degree, the AACN Board of
Directors, in January 2005, created the Task Force on the Essentials of Nursing
Education for the Doctorate of Nursing Practice and charged this task force with
development of the curricular expectations that will guide and shape DNP education.
The DNP Essentials Task Force is comprised of individuals representing multiple
constituencies in advanced nursing practice (see Appendix B). The task force conducted
regional hearings from September 2005 to January 2006 to provide opportunities for
feedback from a diverse group of stakeholders. These hearings were designed using an
iterative process to develop this document. In total, 620 participants representing 231
educational institutions and a wide variety of professional organizations participated in
the regional meetings. Additionally, a national stakeholders’ conference was held in
October 2005 in which 65 leaders from 45 professional organizations participated.
Context of Graduate Education in Nursing
Graduate education in nursing occurs within the context of societal demands and needs as
well as the interprofessional work environment. The Institute of Medicine (IOM, 2003)
and the National Research Council of the National Academies (2005, p. 74) have called
for nursing education that prepares individuals for practice with interdisciplinary,
information systems, quality improvement, and patient safety expertise.
In hallmark reports, the IOM (1999, 2001, 2003) has focused attention on the state of
health care delivery, patient safety issues, health professions education, and leadership for
nursing practice. These reports highlight the human errors and financial burden caused
by fragmentation and system failures in health care. In addition, the IOM calls for
dramatic restructuring of all health professionals’ education. Among the
recommendations resulting from these reports are that health care organizations and
6
groups promote health care that is safe, effective, client-centered, timely, efficient, and
equitable; that health professionals should be educated to deliver patient-centered care as
members of an interdisciplinary team, emphasizing evidence-based practice, quality
improvement, and informatics; and, that the best prepared senior level nurses should be in
key leadership positions and participating in executive decisions.
Since AACN published The Essentials of Master’s Education for Advanced Practice
Nursing in 1996 and the first set of indicators for quality doctoral nursing education in
1986, several trends in health professional education and health care delivery have
emerged. Over the past two decades, graduate programs in nursing have expanded from
220 institutions offering 39 doctoral programs and 180 master’s programs in 1986 to 518
institutions offering 101 doctoral programs and 417 master’s programs in 2006.
Increasing numbers of these programs offer preparation for certification in advanced
practice specialty roles such as nurse practitioners, nurse midwives, nurse anesthetists,
and clinical nurse specialists. Specialization is also a trend in other health professional
education. During this same time period, the explosion in information, technology, and
new scientific evidence to guide practice has extended the length of educational programs
in nursing and the other health professions. In response to these trends, several other
health professions such as pharmacy, physical therapy, occupational therapy, and
audiology have moved to the professional or practice doctorate for entry into these
respective professions.
Further, support for doctoral education for nursing practice was found in a review of
current master’s level nursing programs (AACN, 2004, p. 4). This review indicated that
many programs already have expanded significantly in response to the above concerns,
creating curricula that exceed the usual credit load and duration for a typical master’s
degree. The expansion of credit requirements in these programs beyond the norm for a
master’s degree raises additional concerns that professional nurse graduates are not
receiving the appropriate degree for a very complex and demanding academic experience.
Many of these programs, in reality, require a program of study closer to the curricular
expectations for other professional doctoral programs rather than for master’s level study.
Relationships of Master’s, Practice Doctorate, and Research Doctorate Programs
The master’s degree (MSN) historically has been the degree for specialized advanced
nursing practice. With development of DNP programs, this new degree will become the
preferred preparation for specialty nursing practice. As educational institutions transition
from the master’s to DNP degree for advanced practice specialty preparation, a variety of
program articulations and pathways are planned. One constant is true for all of these
models. The DNP is a graduate degree and is built upon the generalist foundation
acquired through a baccalaureate or advanced generalist master’s in nursing. The
Essentials of Baccalaureate Education (AACN, 1998) summarizes the core knowledge
and competencies of the baccalaureate prepared nurse. Building on this foundation, the
DNP core competencies establish a base for advanced nursing practice in an area of
specialization. Ultimately, the terminal degree options in nursing will fall into two
7
primary education pathways: professional entry degree (baccalaureate or master’s) to
DNP degree or professional entry degree (baccalaureate or master’s) to PhD degree. As
in other disciplines with practice doctorates, some individuals may choose to combine a
DNP with a PhD.
Regardless of the entry point, DNP curricula are designed so that all students attain DNP
end-of-program competencies. Because different entry points exist, the curricula must be
individualized for candidates based on their prior education and experience. For
example, early in the transition period, many students entering DNP programs will have a
master’s degree that has been built on AACN’s Master’s Essentials. Graduates of such
programs would already have attained many of the competencies defined in the DNP
Essentials. Therefore, their program will be designed to provide those DNP
competencies not previously attained. If a candidate is entering the program with a non-
nursing baccalaureate degree, his/her program of study likely will be longer than a
candidate entering the program with a baccalaureate or master’s in nursing. While
specialty advanced nursing education will be provided at the doctoral level in DNP
programs, new options for advanced generalist master’s education are being developed.
DNP Graduates and Academic Roles
Nursing as a practice profession requires both practice experts and nurse scientists to
expand the scientific basis for patient care. Doctoral education in nursing is designed to
prepare nurses for the highest level of leadership in practice and scientific inquiry. The
DNP is a degree designed specifically to prepare individuals for specialized nursing
practice, and The Essentials of Doctoral Education for Advanced Nursing Practice
articulates the competencies for all nurses practicing at this level.
In some instances, individuals who acquire the DNP will seek to fill roles as educators
and will use their considerable practice expertise to educate the next generation of nurses.
As in other disciplines (e.g., engineering, business, law), the major focus of the
educational program must be on the area of practice specialization within the discipline,
not the process of teaching. However, individuals who desire a role as an educator,
whether that role is operationalized in a practice environment or the academy, should
have additional preparation in the science of pedagogy to augment their ability to
transmit the science of the profession they practice and teach. This additional preparation
may occur in formal course work during the DNP program.
Some teaching strategies and learning principles will be incorporated into the DNP
curriculum as it relates to patient education. However, the basic DNP curriculum does
not prepare the graduate for a faculty teaching role any more than the PhD curriculum
does. Graduates of either program planning a faculty career will need preparation in
teaching methodologies, curriculum design and development, and program evaluation.
This preparation is in addition to that required for their area of specialized nursing
practice or research in the case of the PhD graduate.
8
The Essentials of Doctoral Education for Advanced Nursing Practice
The following DNP Essentials outline the curricular elements and competencies that
must be present in programs conferring the Doctor of Nursing Practice degree. The DNP
is a degree title, like the PhD or MSN, and does not designate in what specialty a
graduate is prepared. DNP graduates will be prepared for a variety of nursing practice
roles. The DNP Essentials delineated here address the foundational competencies that are
core to all advanced nursing practice roles. However, the depth and focus of the core
competencies will vary based on the particular role for which the student is preparing.
For example, students preparing for organizational leadership or administrative roles will
have increased depth in organizational and systems’ leadership; those preparing for
policy roles will have increased depth in health care policy; and those preparing for APN
roles (nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse
midwives) will have more specialized content in an area of advanced practice nursing.
Additionally, it is important to understand that the delineation of these competencies
should not be interpreted to mean that a separate course for each of the DNP Essentials
should be offered. Curricula will differ in emphases based on the particular specialties
for which students are being prepared.
The DNP curriculum is conceptualized as having two components:
1. DNP Essentials 1 through 8 are the foundational outcome competencies deemed
essential for all graduates of a DNP program regardless of specialty or functional
focus.
2. Specialty competencies/content prepare the DNP graduate for those practice and
didactic learning experiences for a particular specialty. Competencies, content,
and practica experiences needed for specific roles in specialty areas are
delineated by national specialty nursing organizations.
The DNP Essentials document outlines and defines the eight foundational Essentials and
provides some introductory comments on specialty competencies/content. The
specialized content, as defined by specialty organizations, complements the areas of core
content defined by the DNP Essentials and constitutes the major component of DNP
programs. DNP curricula should include these two components as appropriate to the
specific advanced nursing practice specialist being prepared. Additionally, the faculty of
each DNP program has the academic freedom to create innovative and integrated
curricula to meet the competencies outlined in the Essentials document.
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
9
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, the 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 findings 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.
10
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
measurable without corresponding changes in organizational arrangements,
organizational 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.
11
a. Use advanced communication skills/processes to lead quality improvement
and patient safety initiatives in health care systems.
b. 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.
c. Develop and/or monitor budgets for practice initiatives.
d. Analyze the cost-effectiveness of practice initiatives accounting for risk and
improvement of health care outcomes.
e. 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
12
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 variances 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.
13
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, 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).
14
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 the 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.
1 The use of the term “collaboration” is not meant to imply any legal or regulatory requirements or
implications.
15
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 intraprofessional and
interprofessional teams to create change in health care 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, Healthy 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, determinants 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.
16
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 differentiated 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.
17
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.
Incorporation of Specialty-Focused Competencies into DNP Curricula
DNP education is by definition specialized, and DNP graduates assume a variety of
differing roles upon graduation. Consequently, a major component of DNP curricula
focuses on providing the requisite specialty knowledge for graduates to enact particular
roles in the larger healthcare system. While all graduates demonstrate the competencies
delineated in DNP Essentials 1 through 8, further DNP preparation falls into two general
categories: roles that specialize as an advanced practice nurse (APN) with a focus on
care of individuals, and roles that specialize in practice at an aggregate, systems, or
organizational level. This distinction is important as APNs face different licensure,
regulatory, credentialing, liability, and reimbursement issues than those who practice at
an aggregate, systems, or organizational level. As a result, the specialty content preparing
DNP graduates for various practices will differ substantially.
It is noteworthy that specialties evolve over time, and new specialties may emerge. It is
further recognized that APN and aggregate/systems/organizational foci are not rigid
demarcations. For example, the specialty of community health may have DNP graduates
who practice in APN roles providing direct care to individuals in communities; or,
community health DNP graduates may focus solely on programmatic development with
roles fitting more clearly into the aggregate focus.
The specialized competencies, defined by the specialty organizations, are a required and
major component of the DNP curriculum. Specialty organizations develop competency
expectations that build upon and complement DNP Essentials 1 though 8. All DNP
graduates, prepared as APNs, must be prepared to sit for national specialty APN
certification. However, all advanced nursing practice graduates of a DNP program
should be prepared and eligible for national, advanced specialty certification, when
available.
18
Advanced Practice Nursing Focus
The DNP graduate prepared for an APN role must demonstrate practice expertise,
specialized knowledge, and expanded responsibility and accountability in the care and
management of individuals and families. By virtue of this direct care focus, APNs
develop additional competencies in direct practice and in the guidance and coaching of
individuals and families through developmental, health-illness, and situational transitions
(Spross, 2005). The direct practice of APNs is characterized by the use of a holistic
perspective; the formation of therapeutic partnerships to facilitate informed decision-
making, positive lifestyle change, and appropriate self-care; advanced practice thinking,
judgment, and skillful performance; and use of diverse, evidence-based interventions in
health and illness management (Brown, 2005).
APNs assess, manage, and evaluate patients at the most independent level of clinical
nursing practice. They are expected to use advanced, highly refined assessment skills
and employ a thorough understanding of pathophysiology and pharmacotherapeutics in
making diagnostic and practice management decisions. To ensure sufficient depth and
focus, it is mandatory that a separate course be required for each of these three
content areas: advanced health/physical assessment, advanced physiology/
pathophysiology, and advanced pharmacology (see Appendix A). In addition to
direct care, DNP graduates emphasizing care of individuals should be able to use their
understanding of the practice context to document practice trends, identify potential
systemic changes, and make improvements in the care of their particular patient
populations in the systems within which they practice.
Aggregate/Systems/Organizational Focus
DNP graduates in administrative, healthcare policy, informatics, and population-based
specialties focus their practice on aggregates: populations, systems (including
information systems), organizations, and state or national policies. These specialties
generally do not have direct patient care responsibilities. However, DNP graduates
practicing at the aggregate/systems/organization level are still called upon to define
actual and emerging problems and design aggregate level health interventions. These
activities require that DNP graduates be competent in advanced organizational, systems,
or community assessment techniques, in combination with expert level understanding of
nursing and related biological and behavioral sciences. The DNP graduate preparing for
advanced specialty practice at the population/organizational/policy level demonstrates
competencies in conducting comprehensive organizational, systems, and/or community
assessments to identify aggregate health or system needs; working with diverse
stakeholders for inter- or intra-organizational achievement of health-related
organizational or public policy goals; and, designing patient-centered care delivery
systems or policy level delivery models.
19
Curricular Elements and Structure
Program Length
Institutional, state, and various accrediting bodies often have policies that dictate
minimum or maximum length and/or credit hours that accompany the awarding of
specific academic degrees. Recognizing these constraints, it is recommended that
programs, designed for individuals who have already acquired the competencies in The
Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 1998),
be three calendar years, or 36 months of full-time study including summers or four years
on a traditional academic calendar.
Post-master’s programs should be designed based on the DNP candidate’s prior
education, experience, and choice of specialization. Even though competencies for the
DNP build and expand upon those attained through master’s study, post-master’s and
post-baccalaureate students must achieve the same end-of-program competencies.
Therefore, it is anticipated that a minimum of 12 months of full-time, post-master’s study
will be necessary to acquire the additional doctoral level competencies. The task force
recommends that accrediting bodies should ensure that post-master’s DNP programs have
mechanisms in place to validate that students acquire all DNP end-of-program
competencies. DNP programs, particularly post-master’s options, should be efficient and
manageable with regard to the number of credit hours required, and avoid the
development of unnecessarily long, duplicative, and/or protracted programs of study.
Practice Experiences in the Curriculum
DNP programs provide rich and varied opportunities for practice experiences aimed at
helping graduates achieve the essential and specialty competencies upon completion of
the program. In order to achieve the DNP competencies, programs should provide a
minimum of 1,000 hours of practice post-baccalaureate as part of a supervised academic
program. Practice experiences should be designed to help students achieve specific
learning objectives related to the DNP Essentials and specialty competencies. These
experiences should be designed to provide systematic opportunities for feedback and
reflection. Experiences include in-depth work with experts from nursing as well as other
disciplines and provide opportunities for meaningful student engagement within practice
environments. Given the intense practice focus of DNP programs, practice experiences
are designed to help students build and assimilate knowledge for advanced specialty
practice at a high level of complexity. Therefore, end-of-program practice immersion
experiences should be required to provide an opportunity for further synthesis and
expansion of the learning developed to that point. These experiences also provide the
context within which the final DNP product is completed.
Practice immersion experiences afford the opportunity to integrate and synthesize the
essentials and specialty requirements necessary to demonstrate competency in an area of
20
specialized nursing practice. Proficiency may be acquired through a variety of methods,
such as, attaining case requirements, patient or practice contact hours, completing
specified procedures, demonstrating experiential competencies, or a combination of these
elements. Many specialty groups already extensively define various minimal experiences
and requirements.
Final DNP Project
Doctoral education, whether practice or research, is distinguished by the completion of a
specific project that demonstrates synthesis of the student’s work and lays the
groundwork for future scholarship. For practice doctorates, requiring a dissertation or
other original research is contrary to the intent of the DNP. The DNP primarily involves
mastery of an advanced specialty within nursing practice. Therefore, other methods must
be used to distinguish the achievement of that mastery. Unlike a dissertation, the work
may take a number of forms. One example of the final DNP product might be a practice
portfolio that includes the impact or outcomes due to practice and documents the final
practice synthesis and scholarship. Another example of a final DNP product is a practice
change initiative. This may be represented by a pilot study, a program evaluation, a
quality improvement project, an evaluation of a new practice model, a consulting project,
or an integrated critical literature review. Additional examples of a DNP final product
could include manuscripts submitted for publication, systematic review, research
utilization project, practice topic dissemination, substantive involvement in a larger
endeavor, or other practice project. The theme that links these forms of scholarly
experiences is the use of evidence to improve either practice or patient outcomes.
The final DNP project produces a tangible and deliverable academic product that is
derived from the practice immersion experience and is reviewed and evaluated by an
academic committee. The final DNP product documents outcomes of the student’s
educational experiences, provides a measurable medium for evaluating the immersion
experience, and summarizes the student’s growth in knowledge and expertise. The final
DNP product should be defined by the academic unit and utilize a form that best
incorporates the requirements of the specialty and the institution that is awarding the
degree. Whatever form the final DNP product takes, it will serve as a foundation for
future scholarly practice.
DNP Programs in the Academic Environment:
Indicators of Quality in Doctor of Nursing Practice Programs
Practice-focused doctorates are designed to prepare experts in nursing practice. The
academic environments in which these programs operate must provide substantial access
to nursing practice expertise and opportunities for students to work with and learn from a
variety of practice experts including advanced clinicians, nurse executives, informaticists,
or health policy makers. Thus, schools offering the DNP should have faculty members,
practice resources, and an academic infrastructure that support a high quality educational
program and provide students with the opportunities to develop expertise in nursing
practice. Similar to the need for PhD students to have access to strong research
21
environments, DNP students must have access to strong practice environments, including
faculty members who practice, environments characterized by continuous improvement,
and a culture of inquiry and practice scholarship.
Faculty Characteristics
Faculty members teaching in DNP programs should represent diverse backgrounds and
intellectual perspectives in the specialty areas for which their graduates are being
prepared. Faculty expertise needed in these programs is broad and includes a mix of
doctorally prepared research-focused and practice-focused faculty whose expertise will
support the educational program required for the DNP. In addition to faculty members
who are nurses, faculty members in a DNP program may be from other disciplines.
Initially, during the transition, some master’s-prepared faculty members may teach
content and provide practice supervision, particularly in early phases of post-
baccalaureate DNP curriculum. Once a larger pool of DNP graduates becomes available,
the faculty mix can be expected to shift toward predominately doctorally-prepared faculty
members.
The Faculty and Practice
Schools offering DNP programs should have a faculty cohort that is actively engaged in
practice as an integral part of their faculty role. Active practice programs provide the
same type of applied learning environment for DNP students as active research programs
provide for PhD students. Faculty should develop and implement programs of
scholarship that represent knowledge development from original research for some
faculty and application of research in practice for others. Faculty, through their practice,
provides a learning environment that exemplifies rapid translation of new knowledge into
practice and evaluation of practice-based models of care.
Indicators of productive programs of practice scholarship include extramural grants in
support of practice innovations; peer reviewed publications and presentations; practice-
oriented grant review activities; editorial review activities; state, regional, national, and
international professional activities related to one’s practice area; policy involvement;
and development and dissemination of practice improvement products such as reports,
guidelines, protocols, and toolkits.
Practice Resources and Clinical Environment Resources
Schools with DNP programs should develop, expand, sustain, and provide an
infrastructure for extensive collaborative relationships with practice systems or sites and
provide practice leadership in nursing and other fields. It is crucial for schools offering
the DNP to provide or have access to practice environments that exemplify or aspire to
22
the best in professional nursing practice, practice scholarship in nursing education, and
provide opportunities for interprofessional collaboration (AACN, 2001a). Strong and
explicit relationships need to exist with practice sites that support the practice and
scholarship needs of DNP students including access to relevant patient data and access to
patient populations (e.g., direct access to individuals, families, groups, and communities)
(AACN, 1999). Practice affiliations should be designed to benefit jointly the school and
the practice sites. Faculty practice plans should also be in place that encourage and
support faculty practice and scholarship as part of the faculty role.
Academic Infrastructure
The academic infrastructure is critical to the success of all DNP programs. Sufficient
financial, personnel, space, equipment, and other resources should be available to
accomplish attainment of DNP program goals and to promote practice and scholarship.
Administrative as well as infrastructure support should reflect the unique needs of a
practice-focused doctoral program. For example, this support would be evident in the
information technology, library holdings, clinical laboratories and equipment, and space
for academic and practice initiatives that are available for student learning experiences.
Academic environments must include a commitment to the practice mission. This
commitment will be manifest through processes and structures that reflect a re-
conceptualization of the faculty role whereby teaching, practice, and practice-focused
scholarship are integrated. This commitment is most apparent in systems that are
consistent with Boyer’s recommendations for broader conceptualization of scholarship
and institutional reward systems for faculty scholarship (Boyer, 1990). Whether or not
tenure is available for faculty with programs of scholarly practice, appropriate reward
systems should be in place that endorse and validate the importance of practice-based
faculty contributions. Formal faculty practice plans and faculty practice committees help
institutionalize scholarly practice as a component of the faculty role and provide support
for enhancing practice engagement. Faculty practice should be an essential and
integrated component of the faculty role.
23
Appendix A
I. Advanced Health/Physical Assessment
Advanced health/physical assessment includes the comprehensive history, physical, and
psychological assessment of signs and symptoms, pathophysiologic changes, and
psychosocial variations of the patient (individual, family, or community). If the patient is an
individual, the assessment should occur within the context of the family and community and
should incorporate cultural and developmental variations and needs of the patient. The
purpose of this comprehensive assessment is to develop a thorough understanding of the
patient in order to determine appropriate and effective health care including health promotion
strategies.
There is a core of general assessment content that every advanced practice nurse must have.
Specifics and additional assessment related to various specialties (e.g., women’s health,
mental health, anesthesiology, pediatrics) should be further addressed and refined in that
specialty’s course content within each program. Health/physical assessment must also be
used as a base and be reinforced in all clinical experiences and practicum courses.
Individuals entering an advanced practice nursing program are expected to possess effective
communication and patient teaching skills. Although these are basic to all professional
nursing practice, preparation in the advanced practice nursing role must include continued
refinement and strengthening of increasingly sophisticated communication and observational
skills. Health/physical assessment content must rely heavily on the development of sensitive
and skilled interviewing.
Course work should provide graduates with the knowledge and skills to:
1. demonstrate sound critical thinking and clinical decision making;
2. develop a comprehensive database, including complete functional assessment,
health history, physical examination, and appropriate diagnostic testing;
3. perform a risk assessment of the patient including the assessment of lifestyle and
other risk factors;
4. identify signs and symptoms of common emotional illnesses;
5. perform basic laboratory tests and interpret other laboratory and diagnostic data;
6. relate assessment findings to underlying pathology or physiologic changes;
7. establish a differential diagnosis based on the assessment data; and
8. develop an effective and appropriate plan of care for the patient that takes into
consideration life circumstance and cultural, ethnic, and developmental
variations.
II. Advanced Physiology/Pathophysiology
The advanced practice nurse should possess a well-grounded understanding of normal
physiologic and pathologic mechanisms of disease that serves as one primary component of
the foundation for clinical assessment, decision making, and management. The graduate
should be able to relate this knowledge “to interpreting changes in normal function that result
in symptoms indicative of illness” and in assessing an individual’s response to pharmacologic
24
management of illnesses (NONPF, 1995, p. 152). Every student in an advanced practice
nursing program should be taught a basic physiology/pathophysiology course. Additional
physiology and pathophysiology content relevant to the specialty area may be taught in the
specialty courses. In addition to the core course, content should be integrated throughout all
clinical and practicum courses and experiences. The course work should provide the
graduate with the knowledge and skills to:
1. compare and contrast physiologic changes over the life span;
2. analyze the relationship between normal physiology and pathological phenomena
produced by altered states across the life span;
3. synthesize and apply current research-based knowledge regarding pathological
changes in selected disease states;
4. describe the developmental physiology, normal etiology, pathogenesis, and
clinical manifestations of commonly found/seen altered health states; and
5. analyze physiologic responses to illness and treatment modalities.
III. Advanced Pharmacology
Every APN graduate should have a well-grounded understanding of basic pharmacologic
principles, which includes the cellular response level. This area of core content should
include both pharmacotherapeutics and pharmacokinetics of broad categories of
pharmacologic agents. Although taught in a separate or dedicated course, pharmacology
content should also be integrated into the content of Advanced Health/Physical Assessment
and Advanced Physiology and Pathophysiology courses. Additional application of this
content should also be presented within the specialty course content and clinical experiences
of the program in order to prepare the APN to practice within a specialty scope of practice.
As described above, the purpose of this content is to provide the graduate with the knowledge
and skills to assess, diagnose, and manage (including the prescription of pharmacologic
agents) a patient’s common health problems in a safe, high quality, cost-effective manner.
The course work should provide graduates with the knowledge and skills to:
1. comprehend the pharmacotherapeutics of broad categories of drugs;
2. analyze the relationship between pharmacologic agents and
physiologic/pathologic responses;
3. understand the pharmacokinetics and pharmacodynamics of broad categories of
drugs;
4. understand the motivations of patients in seeking prescriptions and the
willingness to adhere to prescribed regimens; and
5. safely and appropriately select pharmacologic agents for the management of
patient health problems based on patient variations, the problem being managed,
and cost effectiveness.
25
Appendix B
DNP Essentials Task Force
Donna Hathaway, PhD, Chair
Dean, College of Nursing
University of Tennessee Health Science Center
Janet Allan, PhD
Dean, School of Nursing
University of Maryland
Ann Hamric, PhD
Associate Professor, School of Nursing
University of Virginia
Judy Honig, EdD
Associate Dean, School of Nursing
Columbia University
Carol Howe, DNSc
Professor, School of Nursing
Oregon Health and Science University
Maureen Keefe, PhD
Dean, College of Nursing
University of Utah
Betty Lenz, PhD
Dean, College of Nursing
The Ohio State University
(Sr.) Mary Margaret Mooney, DNSc
Chair, Department of Nursing
North Dakota State University – Fargo
Julie Sebastian, PhD
Assistant Dean, College of Nursing
University of Kentucky
Heidi Taylor, PhD
Head, Division of Nursing
West Texas A&M University
26
Edward S. Thompson, PhD
Director, Anesthesia Nursing Program
University of Iowa
Polly Bednash, PhD (Staff Liaison)
Executive Director
AACN
Joan Stanley, PhD (Staff Liaison)
Senior Director, Education Policy
AACN
Kathy McGuinn, MSN (Staff Liaison)
Director, Special Projects
AACN
27
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