DNP Degree: Improving the Barriers
Associated with Access to Health Care in United States
DNP Degree: Improving the Barriers
Associated with Access to Health Care in United States
a. Thesis Statement
Doctorate degree in nursing is an important aspect of professional development achieved through extension of appropriate educational program in the advanced nursing practice. The broad purpose of Doctor of Nursing Practice (DNP) is to prepare and advance the practice of nurses enabling the professional body to expand their scope of practice and participation in the delivery of health care. Despite the negative critiques from detractors of nursing education, the concept of DNP provides an effective professional alternative to improve the increasing clinical trends affecting the barriers in the access of health care delivery, such as increasing chronic illnesses, imbalance in family-centered practitioners and increasing insurance costs.
b. DNP Degree: Problem Overview
Nursing doctoral programs began in the latter twentieth century between 1950s and 1960s after its distinct advancement of practice from outside the mainstream of higher education (Andrist, Nicholas and Wolf, 2006 p.387). According to Joel (2006), various American universities providing nursing education limits their degrees to doctoral instead of PhD because of an existing notion that nursing science is not as advanced compared to other fields of health science (p.227). However, due to the growing need for clinical practitioners to cater the increasing number of clinical cases, DNP concept has been chosen to expand the practice of nurses from theory-based to practice-based nursing (Keating, 2006 p.409). Eventually, higher educational degree of DNP has been made available by various nursing universities aiming to answer the evolving health care trend in society. The 2004 DNP degree from the American Association of Colleges of Nursing (AACN) plays an important role in the expansion of courses associated with other fields, such as advanced clinical courses, informatics, community organizing, dedicated in the advancement of nursing scope of practice (Fairman, 2008 p.193).
Currently, there have been health concerns associated with the increasing trends of chronic disabilities requiring family-based and chronic disease-care measures. According to the Center for Disease Control and Prevention (CDC), chronic illnesses account for more than 75% of the American health care expenditures amounting to U.S. $1.4 trillion medical care costs (Lubkin and Larsen, 2006 p.647). Most of the chronic conditions require family health interventions and monitoring; however, the availability of family physicians and family-based practice enrollees are declining consistently (Thurber and Busing, 1999). If this continues, imbalances in the health care delivery compromising the quality of delivered care might occur especially among patients requiring practice-based care measures. Hence, AACN views the need for a doctoral education that can enhance advanced practice nursing. Proponents of nursing doctoral programs contend the need to prepare nursing practitioners for higher levels of nursing practice to expand their participation in the growing demand of health care (Keating, 2006 p.409).
c. Scopes and Limitations
The paper addresses the impacts of the newly developed DNP education in the advancement of nursing practice. Despite the negative comments on doctoral practice of nursing, many nursing associations believe its dramatic impact in the health care delivery system. The paper answers the following statements based on recent scholarly studies and references:
Ø DNP concept and its impact in the practice of nursing
Ø DNP and its role in the health care of chronic medical conditions
Ø DNP and its impact in the health care costs
Ø DNP as a reliever in family-based health practices
a. DNP Degree and Practice of Nursing
Doctoral programs of nursing initiates a practice-based doctoral education in order to prepare nurses for leadership in practice, and for specialized advanced practice and administrative function (Fitzpatrick and Wallace, 2005 p.154). Joel (2006) defines DNP as an advanced practice with emphasis on functional roles associated in various fields, such as clinical, education or leadership/management (p.227). As of 2005, there are over 88 institutions offering doctoral programs on both research-based (e.g. Doctor of Nursing Sciences –DNS, etc.) and practice-based nursing (e.g. DNP, Doctor of Nursing – DN, etc) (Fitzpatrick and Wallace, 2005 p.154). According to Clinton and Sperhac (2006), DNP – the terminal degree on practice-based nursing – provides a promising role in improving the barriers of access to health care.
On October 2004, AACN member institutions voted to formalize the doctoral program for DNP degree aiming to advance the practice of nursing at a doctoral level by the year 2015 (Hathaway, 2006). However, various issues pertaining to DNP programs have also aroused in forums, debates and questioning made by the members of nursing body. According to Fairman (2008), various nurse educators from higher nursing universities consider DNP education as unnecessary, risky and unable to address the public need (p.193). In addition, DNP concept is viewed as a negative influence in research-based higher education, such as Ph.D. programs, due to the division of enrollments affecting education budget needed by nursing faculties and researchers (Fairman, 2008 p.193). The study of Dracup, Cronenwett and Meleis (2005) also suggest that the implementation of DNP will threaten the discipline on theory-based nursing by lengthening the course of study to a PhD, which consequently shortens the productive scientific careers. Nonetheless, the decision made by AACN member institutions and stakeholders calls for a transformation in the profession’s education to better improve the barriers in the access of health care and to suit the increasing need for the expansion of nursing health practice (Hathaway, 2006). As supported by Bartels (2005), DNP program equips nurses with higher levels of education, practice-based knowledge, and skills transforming their scope of practice from supportive to specialized clinical nursing care. Advancing the practice of nursing through DNP may answer in the need for family medical practitioners, render to the increasing trend of chronic conditions, and answer the increasing health care costs (Boyd, 2007 p.50).
b. Current Problems of Health Care in United States
Practice-focused doctoral programs, such as DNP, have been considered as viable alternatives to the theory-based doctorate programs (DNS) due to its concentrations in the practical applications of nursing practice, especially in the fields of organization and system leadership, change strategies and quality improvement, analytic methodologies and application of evidence-based practice (Fitzpatrick and Wallace, 2005 p.155). According to Paul and Heaslip (2008), DNS applications and doctoral transformations aimed by AACN address the current health care trend, specifically in the increasing chronic care demands, and imbalances in practitioners capable of addressing these demands. In the October 2004 Position Statement addressed by AACN, DNP transition from graduate to doctoral level of practice acts as a “…response to changes in health care delivery and emerging health care needs, additional knowledge or content areas have been identified by practicing nurses” (AACN, 2004).
According to the study of Dracup and Bryan-Brown (2005), the number of BSN graduates has dramatically increased from 2000 to 2005 alone; however, only 44% of 2.7 million American graduate nurses pursue higher degrees of practice. Adding to the decreasing numbers of nursing graduates pursuing higher education, medical practitioners, especially family-based practice, have also declined over the past few years (Thurber and Busing, 1999). In effect, the need for practitioners who can delivery complex and higher health care arises and eventually worsens the barriers of access to health care. Hence, DNP degree holders are necessary to fill in these needs and health care demands.
i. Imbalances of Practice
According to AACN (2006), there has been a tremendous increase in the number of institutions providing doctoral and master’s programs from 1986 to 2006. In 1986, graduate programs in nursing offered by 220 institutions has been determined to consist 39 doctoral and 180 master’s education program, while in the year 2006, the number of institutions offering higher education has increased to 518 and these organizations offer 101 doctoral and 417 master’s program. Despite the increasing number of institutions offering higher nursing education, and programs offering doctorate and master’s education, Berlin (2002) has identified 18.2% marked decline in the number of nursing faculties and practicing nurses who have reached higher education.
Aiken, Clarke and Cheung et al. (2003) have proven the positive impacts of higher proportions of nurses educated at baccalaureate or higher levels of education to the overall health care delivery system. Based on their study results, 10% increase in the proportion of degree-holder nurses has been associated with 5% decrease in mortality rates within 30 days of admission (Aiken, Clarke and Cheung et al., 2003). Based on the literary reviews conducted in the study of Goodin (2003), American health care and the public’s access to quality nursing and medical care are influenced by the shortage and surplus of registered nurses from 1999 to 2001. Furthermore, According to the study of Thurber and Busing (1999), there has been a marked decline of medical professionals entering family practice from 1991 to 1998. Based on statistics, 890 physicians (51% of graduates) were trained as family physicians in 1993. After a year, the proportion remained at 40% but number of graduates enrolling for family practice had declined to 646, and by 1998, to 619 (Thurber and Busing, 1999). If the imbalance of profession continues to arise, the availability of quality and secured health care among public can greatly decline. AACN (2006) suggests the advancement of practice through DNP programs in order to prepare nurse practitioners for higher practice and to expand their scope of practice.
ii. Chronic Medical Conditions
Massive studies indicating the rising trend of chronic diseases are now being published on a wide-scale basis in United States. According to U.S. Bureau of Epidemiology, more than 15% of American adult population suffers chronic disabling condition, such as arthritis, cardiovascular disorders, etc (DOH State Florida, 2007). American Medical Association (AMA) points chronic diseases as the primary responsible for approximately 70% of all deaths in U.S (Pan, 2007), while World Health Organization (WHO) holds chronic diseases responsible for approximately 60% of 2005 international deaths. Pan (2007) cites the projected increase in cases of chronic diseases from 2003 to 2023 with a population growth of 19%. According to statistics acknowledged by AMA, projected trend of chronic diseases from 2003 to 2023 shows marked increase, such as cancer conditions accounting to 62%, 54% for mental disorders, 53% for diabetes, 41% for heart diseases, 39% for hypertension, 31% for pulmonary conditions, and 29% for stroke (Pan, 2007). With the increasing trends of chronic conditions, high demographical demands and insufficiency for nursing and medical care become significant barriers to the public’s access to health care.
The aims of DNP programs include the preparation of nurse practitioners in confronting clinical complexities and addressing quality assured health care process for the patient. The task of handling, managing and treating patients with chronic conditions is one of the primary skills harnessed in the course curriculum of DNP. According to Wolff, Starfield and Anderson (2002), controlled samples of nurses with higher degrees of education have shown dramatic improvements in prevention of chronic disease complications. In addition, Bodenheimer, MacGregor and Stothart (2005) conclude that nurses are the keys in successfully implementing the widely accepted chronic care model, which is an established standard for improving chronic care for individuals with chronic disorders. Lastly, Holm-Frich (2003) points out that patients with chronic conditions often benefit from nursing community- and family-based care approaches. The outcomes of the study indicated high patients’ satisfaction, good clinical outcomes, and cost cut from hospital-based care measures (Holm-Frich, 2003).
Vrijhoef, Diederiks and Spreeuwenberg (2002) have determined the effectiveness of advanced nursing practice with doctoral degree in caring of diabetic outpatients due to its expanded reach of care and multi-disciplinary approach consisting of pharmacological, medical, community-based, family and other disciplines associated with primary care. Indeed, degree advancement in the practice of nursing through doctoral programs allows the expansion of nursing care from the fundamental degree of practice (e.g. community organizing, nursing diagnosis, nursing process, etc.) to higher forms of effective and multi-disciplinary nursing care.
iii. Health Care Costs
The idea of DNP program is to provide nurse practitioners with multi-disciplinary courses aiming to prepare them from the general conditions that can be confronted in their area of practice (Bryan-Brown, 2005). Added by Marecki (2007), shortages of work force, incompetence in practice, unachieved collaborative functions and faulty referral system increase the health care costs of both insured and uninsured patients. According to Medicare Expenditure reports in 2004, annual uninsured medical expenditures have reached almost U.S $125 billion, while uncompensated care expenditures reached to a total of U.S $40.7 billion (Hadley and Holahan, 2004). Cost-affecting conditions can be controlled by expanding the nursing scope of practice through DNP education that can lower patient-physician-patient ratio, increase workforce retention, and eventually lowering workforce-demand ratio, which cuts the cost of medical expenditures (Marecki, 2007).
c. DNP Degree: The Barriers to Health Care
The identified barriers to health care, namely (a) increasing trend of chronic illnesses, (b) practitioner imbalances in the area of primary care and (c) increasing costs of health care, can be addressed by implementing DNP programs to expand the nursing scope of practice. According to Andrist, Nicholas and Wolf (2006), the profession of nursing is the most comprehensive of all the health professionals since clinical practice of nursing demands an “understanding of human condition, the environments in which clients live, the systems of care delivery, and political milieu of care” (p.390).
Unfortunately, according to Dracup and Bryan-Brown (2005), the produced advanced-practicing nurses remain the smallest accounting to approximately 11%, which can be subdivided into practitioners with master’s degree (10%) and doctoral degree (less than 1%). Unlike master’s program, DNP education provides an education oriented to the actual scenarios encountered within the complex fields of nursing. Dracup and Bryan-Brown (2005) have cited three significant advantages of DNP if it is to replace MS Degree, namely (a) a parity with other health care disciplines (e.g. mandating DNP degree among nurses who practice higher positions – administrative/managerial, etc.), (b) decrease of credit compared to the requirements of MS degree allowing more clinical experience than theory and research experiences, and (c) DNP prepares nurses for the different complexities of clinical practice in the area.
d. DNP: Filling in the Void
With the decreasing availability of medical practitioners and nurses versus the increasing trends of chronic illnesses, the issue on accessibility of care has been acknowledged by most medical (AMA) and nursing associations (AACN) aiming to determine strategies to counter the shortage of health care providers. In order to resolve the issue, AACN has established DNP program to prepare nursing practitioners for higher health coverage to fill in the shortage of health care output. According to Wall, Novak and Wilerson (2005), DNP program utilizes an interdisciplinary course curriculum from post-baccalaureate to doctorate degree emphasizing on “health care engineering and interdisciplinary collaboration among faculty, hospitals, community leaders, and policymakers.” Mundinger, Cook and Lenz et al. (2000) have mentioned the need for DPN in filling in not only the shortage of available family- and community-oriented medical practitioners, but mainly to increase the health care output via the expansion of nursing scope of practice. DNP degree nurse practitioners allow higher nursing interventions from prescribing medications to diagnostics (Joel, 2006 p.227). With the multidisciplinary and comprehensive enhancement of DNP curriculum and course education, doctorate nurses oriented in practice-based health care should be able to handle the void caused by the shortages or decline in the population of available health care providers; thereby, improving the barriers in the access of health care.
In conclusion, DNP education has been acknowledged by AACN, AMA and various organizations as a promising higher educational nursing program. DNP degree of nursing practice is oriented in a practice-based approach utilizing the fundamental theories of nursing and applying it to the growing complexities of health care. Supported by various scholarly studies, the comprehensive, multidisciplinary and expanded scope of practice provided by DNP program should effectively address the growing concerns on the barriers in the access of health care, namely (a) imbalances in the availability of health care providers, (b) increasing trends of chronic illnesses and (c) increasing health care costs. Despite the negative comments against DNP, position statement made by AACN addresses the formal establishment of DNP programs by 2015, which formalizes DNP as the terminal education program for advanced nursing practice.
AACN, (2004, October). AACN Position Statement on the Practice Doctorate in Nursing October 2004. Retrieved November 12, 2008, from American Association of Colleges of Nursing: http://www.aacn.nche.edu/DNP/pdf/DNP.pdf
AACN, (2006, October). The Essentials of Doctoral Education for Advanced Nursing Practice. Retrieved November 12, 2008, from American Association of Colleges of Nursing: http://www.aacn.nche.edu/DNP/pdf/Essentials.pdf
Aiken, L. H., Clarke, S. P., & Cheung et al., R. B. (2003, January). Educational Levels of Hospital Nurses and Surgical Patient Mortality . The Journal of Medical Association, 290, 1617-1623.
Andrist, L. C., Nicholas, P. K., & Wolf, K. (2006). A History of Nursing Ideas. New York, U.S.A: Jones & Bartlett Publishers.
Bartels, J. E. (2005, November). Educating nurses for the 21st century. Nursing & Health Sciences, 7, 221 – 225.
Berlin, L. (2002, January). The shortage of doctorally prepared nursing faculty: A dire situation. Nursing Outlook, 2, 50 – 56.
Bodenheimer, T. L., MacGregor, K., & Stothart, N. (2005, January). Nurses as leaders in chronic care . British Medical Journal, 330, 612-613.
Boyd, M. A. (2007). Psychiatric Nursing: Contemporary Practice. New York, U.S.A: Lippincott Williams & Wilkins.
Clinton, P., & Sperhac, A. (2006, January). National Agenda for Advanced Practice Nursing: The Practice Doctorate. Journal of Professional Nursing, 22, 7 – 14.
DOH State Florida, (2007, June). Chronic Disease Epidemiology Surveillance and Evaluation. Retrieved November 12, 2008, from Florida Department of Health: http://www.doh.state.fl.us/Disease_ctrl/epi/Chronic_Disease/Chronic_Disease.htm
Dracup, K., & Bryan-Brown, C. W. (2005, January). Doctor of Nursing Practice—MRI or Total Body Scan? . American Journal of Critical Care, 14, 278-281.
Dracup, K., Cronenwett, L., & Meleis et al., A. (2005, January). Reflections on the doctorate of nursing practice. Nursing Outlook, 53, 177 – 182.
Fairman, J. (2008). Making Room in the Clinic: Nurse Practitioners and the Evolution of Modern Health Care. New York, London: Rutgers University Press.
Fitzpatrick, J. J., & Wallace, M. (2005). Encyclopedia of Nursing Research. New York, U.S.A, London: Springer Publishing Company.
Goodin, H. (2003, July). The nursing shortage in the United States of America: an integrative review of the literature. Journal of Advanced Nursing, 43, 335 – 343.
Hadley, J., & Holahan, J. (2004, May). The Cost of Care for the Uninsured: What Do We Spend, Who Pays, and What Would Full Coverage Add to Medical Spending?. Kaiser Commission on Medicaid and the Uninsured, 1, 1-12.
Hathaway, D. (2006, January). Introducing the Doctor of Nursing Practice. Medscape General Medicine, 8, 1-7.
Holm-Frich, L. L. (2003, October). Nursing interventions for patients with chronic conditions. Journal of Advanced Nursing, 44, 137 – 153.
Joel, L. A. (2006). The Nursing Experience: Trends, Challenges, and Transitions. New York, U.S.A: McGraw Hill Professional.
Keating, S. B. (2006). Curriculum Development and Evaluation in Nursing. New York, U.S.A: Lippincott Williams & Wilkins.
Lubkin, I., & Larsen, P. D. (2006). Chronic Illness: Impact and Interventions. New York, U.S.A: Jones & Bartlett Publishers.
Marecki, M. (2007, June). Is the Doctor of Nursing Practice (DNP) the Appropriate Doctoral Degree for Nurses?. The American Journal of Maternal/Child Nursing, 32, 139 – 139 .
Mundinger, M. O., Cook, S. S., & Lenz et al., E. R. (2000, December). Assuring quality and access in advanced practice nursing: a challenge to nurse educators. Journal of Professional Nursing, 16, 322-329.
Pan, R. (2007, November 9). AMA and the Medical Home. Retrieved November 10, 2008, from American Medical Association: http://www.ama-assn.org/ama1/pub/upload/mm/377/i07-pan.pdf
Paul, R. W., & Heaslip, P. (2008, January). Critical thinking and intuitive nursing practice. Journal of Advanced Nursing, 22, 40-47.
Thurber, A. D., & Busing, N. (1999, January). Decreasing supply of family physicians and general practitioners. Serious implications for the future.. Journal of Canadian Family Physician, 45, 2084-2089.
Vrijhoef, H. J., Diederiks, J. P., & Spreeuwenberg, C. (2002, January). Substitution model with central role for nurse specialist is justified in the care for stable type 2 diabetic outpatients. Journal of Advanced Nursing, 36, 546 – 555.
Wall, B. M., Novac, J. C., & Wilkerson, S. A. (2005, September). octor of nursing practice program development: reengineering health care. The Journal of Nursing Education, 44, 396-403.
WHO, (2005, January). Chronic diseases. Retrieved November 12, 2008, from World Health Organization: http://www.who.int/topics/chronic_diseases/en/
Wolff, J. L., Starfield, B., & Anderson, G. (2002, June). Prevalence, Expenditures, and Complications of Multiple Chronic Conditions in the Elderly . Archives of Internal Medicine, 162, 2269-2276.