AACN Position Statement on the

Practice Doctorate in Nursing

October 2004
Practice-focused doctoral degree programs in nursing are not a recent development. The first
such program, offering the Doctor of Nursing (ND), was established at Case Western Reserve
University in 1979 and offered an entry-level nursing degree. Since then, several practice-
focused doctoral programs and degree titles have emerged. Over the last several years, an
increased interest in developing a viable alternative to the research-focused degrees, [Doctor
of Philosophy (PhD) and Doctor of Nursing Science (DNS, DNSc, DSN)] has occurred.
Currently, eight clinical or practice doctoral nursing programs exist or are in the approval
stage. In March 2002, the American Association of Colleges of Nursing (AACN) Board of
Directors charged a task force to examine the current status of clinical or practice doctoral
programs, compare various models, and make recommendations regarding future
development. The exact charge to the 11-member Task Force on the Clinical Doctorate was:
• clarify the purpose of the professional clinical doctorate, specifically core
content and core competencies;
• describe trends over time in clinical doctoral education;
• assess the need for clinically focused doctoral programs;
• identify preferred goals, titles, outcomes, and resources;
• discuss the elements of a unified approach versus a diverse approach;
• determine the potential implications for advanced practice nursing (APN)
programs;
• make recommendations regarding related issues and resources; and
• describe potential for various tracks or role options.

To address this charge the Task Force carried out the following activities:
• reviewed literature regarding professional practice doctorates in nursing and
other disciplines and printed materials and web pages from all institutions
offering practice-focused doctoral programs in nursing;
• established a collaborative relationship with the National Organization of
Nurse Practitioner Faculty (NONPF); the Chair of the NONPF Practice
Doctorate Task Force, Dr. Lucy Marion, serves on the AACN Task Force and
Dr. Elizabeth Lenz, AACN Task Force Chair, participated in a teleweb
conference sponsored by NONPF in February, 2003;
• interviewed key informants (deans, program directors, graduates, and current
students) at the eight current or planned practice-focused doctoral programs in
the United States;
• held open discussions regarding issues surrounding practice-focused doctoral
education at AACN’s Doctoral Education Conference (January 2003 and
February 2004), Master’s Education Conference (March 2003), and Spring
Annual Meeting (March 2004);

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Position Statement on the Practice Doctorate in Nursing

• co-sponsored with NONPF an open discussion on practice doctorates to which

representatives from key nursing organizations and schools of nursing
offering or planning a practice doctoral program were invited (December
2003).
• invited an External Reaction Panel, consisting of 10 individuals representing a
wide array of perspectives and disciplines outside of nursing, to respond to the
Draft Position Statement on the Practice Doctorate (February 2004). The list
of External Reaction Panel members is shown in Appendix A.

BACKGROUND

In November 1999, the Institute of Medicine (IOM) issued the comprehensive report on
medical errors, To Err is Human: Building a Safer Health System. The report, extrapolating
data from two previous studies, estimates that somewhere between 44,000 and 98,000
Americans die each year as a result of errors in health care. These numbers, even at the lower
levels, exceed the number of people that die from motor vehicle accidents, breast cancer, or
AIDs. Total national costs of preventable adverse healthcare events (injury from errors) were
estimated to be between $17 billion and $29 billion, of which health care costs represented
over one-half. In addition, medication-related and other errors that do not result in actual
harm not only are extremely costly as well but have a significant impact on the quality of
care and health care outcomes. The IOM report also focused on the fragmented nature of the
health care delivery system and the context in which health care is purchased as being major
contributors to the high and inexcusable error rate and compromises in patient safety.

The IOM report, Crossing the Quality Chasm (2001), stresses that the health care system as
currently structured does not, as a whole, make the best use of its resources. The aging
population and increased client demand for new services, technologies, and drugs contribute
to the increase in health care expenditures, but also to the waste of resources.
Recommendation two in the report calls on all health care organizations and professional
groups to promote health care that is safe, effective, client-centered, timely, efficient, and
equitable (p. 6).

In a follow-up report, Health Professions Education: A Bridge to Quality (2003a), the

Institute of Medicine Committee on the Health Professions Education states, “All health
professionals should be educated to deliver patient-centered care as members of an
interdisciplinary team, emphasizing evidence-based practice, quality improvement
approaches, and informatics (p. 3).”

Recent management decisions in our nation’s health care organizations have expanded the
responsibilities of chief nursing executives to encompass other patient care services, in
addition to nursing. In addition, the loss of mid-level nurse managers and increased
responsibility of those remaining have decreased the direct management support to patient
care staff (IOM, 2003b). This has resulted in a need for increased knowledge and skills for
clinical and administrative leadership across services and sites of healthcare delivery. To

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Position Statement on the Practice Doctorate in Nursing

respond to this critical issue, the IOM committee recommended several strategies to get the
best prepared clinical nursing leadership at the most senior levels of management, including
the acquisition of nurse leaders for all levels of management and the participation by nursing
management in executive decisions within the healthcare organization (IOM, 2003b, p.8).

Nursing has many of the answers to the predominant health care dilemmas of the future,
including:
• the problems associated with normal human development, particularly aging;
• chronic illness management in all ages;
• health disparities associated with socioeconomic dislocations such as global
migration, classism, sexism; and
• the need for health promotion and disease prevention.
Transforming health care delivery recognizes the critical need for clinicians to design,
evaluate, and continuously improve the context within which care is delivered. The core
function of health care is to provide the best possible clinical care to individuals, families and
communities. The context within which care is delivered exerts a major impact on the kinds
of care that are provided and on the satisfaction and productivity of individual clinicians.
Nurses prepared at the doctoral level with a blend of clinical, organizational, economic and
leadership skills are most likely to be able to critique nursing and other clinical scientific
findings and design programs of care delivery that are locally acceptable, economically
feasible, and which significantly impact health care outcomes.

Context

Doctoral programs in nursing and other practice disciplines can be categorized into two
distinct types: research-focused and practice-focused.
The term practice, specifically nursing practice, as conceptualized in this document
refers to 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.
Preparation at the practice doctorate level includes advanced preparation in nursing,
based on nursing science, and is at the highest level of nursing practice.

What distinguishes this definition of practice from others is that it includes both direct care
provided to patients by individual clinicians as well as direct care policies, programs and
protocols that are organized, monitored, and continuously improved upon by expert nurse
clinicians.

The two types of doctorates ─ research-focused and practice-focused ─ may co-exist within
the same nursing education unit. The majority of research-focused programs in nursing offer
the academic doctorate, the PhD. However, some programs offer a professional doctorate,
such as the DNS or DNSc. In developing the Quality Indicators for Doctoral Nursing
Programs, the AACN Task Force on Quality Doctoral Education found few differences

3
Position Statement on the Practice Doctorate in Nursing

between PhD and professional degree programs’ (DNS or DNSc) curricula and requirements.
Therefore, that Task Force recommended these programs be designated research-focused
doctoral programs and are addressed in AACN’s Position Statement on Quality Indicators for
Doctoral Programs (2001).

The second category of doctoral nursing education programs are the practice-focused
programs. Examples of practice-focused degrees offered in other disciplines include entry-
level degrees [e.g., the Doctor of Medicine (MD), Doctor of Dental Surgery (DDS)], and
those that offer advanced practice degrees [e.g., the Doctor of Psychology (PsyD)]. In nursing,
two institutions (the University of Colorado and Case Western Reserve University) currently
offer a practice-focused doctoral degree (ND) as an entry-level degree.1 Practice-
focused, advanced practice doctoral degrees currently offered in nursing include a Doctor of
Nursing (ND) at Case Western Reserve University, Rush University, and the University of
South Carolina; a DNSc at the University of Tennessee, Memphis; and the Doctor of Nursing
Practice (DNP) at the University of Kentucky. Columbia University has received institutional
approval for a Doctor of Nursing Practice (DrNP) program, and the University of Iowa is in
the exploratory phase of developing a practice-focused doctoral degree program The DNSc,
except at the University of Tennessee, Memphis, is used to designate a research-focused
degree in nursing. The focus of this position paper is the practice-focused doctoral program
that prepares nurses for advanced nursing practice.

Recommendation 1: The Task Force recommends that the terminology, practice

doctorate be used instead of clinical doctorate.

Trends and Current Practice-Focused Doctoral Nursing Programs

The first ND program was established as an entry-level practice doctorate analogous to the
MD and did not provide specialty preparation. The ND graduate wanting to specialize or
prepare for an advanced practice role was expected to earn a master’s degree. Despite much
initial fanfare, there has been considerable confusion within nursing and with the public
regarding the competencies of graduates and the roles within the health care delivery system
they were prepared to fill. Case Western Reserve University ultimately expanded its ND
degree program beyond the original conceptualization to include advanced practice specialty
content and permitted multiple entry points, including entry for nurses with either
baccalaureate or master’s preparation in nursing, as well as those with degrees in other
disciplines.

It can be surmised that as a result of the initial confusion surrounding the ND, relatively few
institutions (four) currently offer the ND degree. In addition, there is some, but not complete,
consistency among these four programs. The most problematic area of confusion is whether
the degree is an entry-level degree or an advanced practice degree. Of the four
existing ND programs, two (Case Western Reserve University and the University of South
1
The University of Colorado and Case Western Reserve University offer multiple entry and multiple exit points
for the ND degree. The direct entry option for non-nurse college graduates has been maintained, and a post-
baccalaureate RN entry option has been added.

4
Position Statement on the Practice Doctorate in Nursing

Carolina) prepare individuals for advanced practice nursing but require students to write a
practice-related dissertation. A recent evolution of one of the programs (Rush University) has
changed its focus from hands-on or direct advanced clinical practice to leadership and
business and requires a practice-focused capstone project. The University of Colorado and
Case Western Reserve University currently are the only institutions to offer an ND program
as an entry-level degree or pre-licensure option. Graduates of the University of Colorado ND
program, in addition to entry-level preparation, can be certified in case management.

Two established practice-focused degree programs include the University of Tennessee,

Memphis, which opened a practice-focused DNSc program in July 1999 and the University
of Kentucky, which opened a DNP program in Fall 2001. Both of these programs admit
master’s-prepared students with expertise in an area of advanced practice nursing. The
University of Tennessee, Memphis program requires a dissertation and confers the DNSc
degree. The University of Kentucky program confers the DNP and requires a capstone
project rather than a dissertation. The University of Tennessee, Memphis program allows
students to develop their own area of specialization. The University of Kentucky program
offers specializations in executive management and population-based clinical practice.

In addition to the existing programs described, two institutions are pursuing approval for new
practice-focused doctoral programs. Columbia University has received university approval
for a DrNP program and is in the process of approval and registration of the new degree title
with New York State. The curriculum plan was developed with the intent of producing
APNs2 who can utilize skills and knowledge to independently provide expert advanced
primary care to patients in all care settings. The University of Iowa is exploring a DNP
program that is grounded in specialty practice and will provide students opportunities for
residencies in administration, education and direct practice. Students for both programs will
be admitted post-baccalaureate (BSN) or following a generic or specialized master’s degree.

The Task Force on the Professional Clinical Doctorate’s 2002 interviews of administrators,
students, and graduates of practice-focused nursing programs revealed considerable
variation. Differentiation between research-focused and practice-focused doctoral programs
has been an ongoing concern, because all institutions offering a practice-focused doctorate
also offer a research-focused nursing doctorate. Discernable differences between the
practice-focused programs and the research-focused programs do exist. These differences
include:
• less emphasis on theory and meta-theory;
• considerably less research methodology content, with the focus being on evaluation
and use of research rather than conduct of research;
• different dissertation requirements, ranging from no dissertation to theses or capstone
projects (termed dissertations in some programs) that must be grounded in clinical
practice and designed to solve practice problems or to inform practice directly;

2
Advanced Practice Nurses (APNs) is used here to refer to the four direct care roles: certified nurse midwife
(CNM), certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), and nurse practitioner
(NP).

5
Position Statement on the Practice Doctorate in Nursing

• an emphasis on practice in any research requirement;

• clinical practica or residency requirements; and
• emphasis on scholarly practice, practice improvement, innovation and testing of
interventions and care delivery models, evaluation of health care outcomes, and
expertise to inform health policy and leadership in establishing clinical excellence
(Marion, Viens, O’Sullivan, Crabtree, Fontana, & Price, 2003).

A review of the specialized emphases or tracks within the existing practice-focused programs
revealed that in general they fall into three major categories of practice: 1) direct care of
individual patients; 2) care of patient populations, including community health nursing; and
3) practice that supports patient care. The latter category includes organizational and
professional leadership, management, health policy, and nursing/health informatics.

In addition to advanced nursing practice foci, the 2002 survey conducted by the AACN Task
Force on the Professional Clinical Doctorate identified core content areas and competencies
common to all practice-focused nursing doctoral programs. Despite variation in the time and
attention devoted by each program to each area, the five common content areas are (in order
of decreasing emphasis):
• advanced clinical practice, including both patient and practice management (on
average, this constituted 33% of content emphasis within programs);
• organizations and systems, and leadership skills (average 19% of content
emphasis);
• research methods, including accrual and use of evidence to improve practice
(average 19%);
• basic scientific underpinnings for practice, including emerging areas of science,
such as genetics and psychoneuroimmunology (average 9%); and
• informatics, use of technology and information (average 8.5%).

The programs surveyed differed in the content area that constituted the primary focus of the
program, i.e., represented over 40% of the content. Clinical practice was the primary focus of
two programs, organizational leadership was the focus of one program, and research was
named as the focus of one program (leading one to question whether the program is in fact
research- and not practice-focused). Dual foci, direct clinical practice and organizational
leadership, characterized three of the programs. The content foci were not consistent with
degree names.

Need and Perceived Benefits

During the past three decades the doctorate has become firmly established as the terminal
degree in nursing. As programs developed, priority was placed on research-focused
education that would lay the groundwork for knowledge development in the field.
Tremendous strides have been made in the development of nursing science. At the same time
research-focused doctoral programs were expanding, master’s degree programs were moving
from an emphasis on role preparation (e.g., educator, administrator) to an emphasis on
specialized clinical knowledge and practice (advanced practice nursing).

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Position Statement on the Practice Doctorate in Nursing

The growing complexity of health care, burgeoning growth in scientific knowledge, and
increasing sophistication of technology have necessitated master’s degree programs that
prepare APNs 3 to expand the number of didactic and clinical clock hours far beyond the
requirements of master’s education in virtually any other field. From 1995 to 2000, the mean
number of semester credit hours required for the NP master’s degree remained stable;
however, the didactic and supervised clinical practice hours increased by 72 and 36 clock
hours, respectively (AACN & NONPF, 2002). Many NP master’s programs now exceed 60
credits and cannot be completed in less than three years. Faculty have identified additional
content areas needed, particularly information and practice management (Bellack, Graber,
O’Neil, Musham, & Lancaster, 1999). In addition, even with the expanded credit
requirements, practicing NPs identify content areas, including practice management, health
policy, use of information technology, risk management, evaluation of evidence, and
advanced diagnosis and management, in which they perceive the need for additional training
(Lenz, Mundinger, Hopkins, Clark, & Lin, 2002).

Based on this information, two challenges are evident:

• Master’s prepared advanced practice nurses identify additional knowledge that is
needed for a higher level of advanced practice.
• The time spent in master’s level nursing education is not congruent with the degree
earned.

In response to changes in health care delivery and emerging health care needs, additional
knowledge or content areas have been identified by practicing nurses. In addition, the
knowledge required to provide leadership in the discipline of nursing is so complex and
rapidly changing that additional or doctoral level education is needed.

Based on input from several stakeholder groups, including attendees at the AACN master’s
and doctoral conferences, the NONPF annual meeting, the NONPF teleweb conference, the
Committee on Institutional Cooperation (CIC) deans’ group4, the multi-disciplinary group
attending the invitational DrNP planning conferences convened by Columbia University, and
the National Forum co-hosted by AACN and NONPF, benefits of practice-focused doctoral
programs include:
• development of needed advanced competencies for increasingly complex
clinical, faculty and leadership roles;
• enhanced knowledge to improve nursing practice and patient outcomes;
3
Advanced Practice Nurses (APNs) is used here to refer to the four direct care roles: certified nurse midwife
(CNM), certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), and nurse practitioner
(NP).
4
The CIC deans group, comprised of directors/deans of schools of nursing in the Big Ten Conference, includes
deans/directors of schools of nursing from the following institutions: Indiana University, Purdue University,
Michigan State University, The Ohio State University, Pennsylvania State University, University of Illinois
Chicago, University of Iowa, University of Michigan, University of Minnesota, University of Wisconsin
Madison, and University of Wisconsin Milwaukee.

7
Position Statement on the Practice Doctorate in Nursing

• 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., clinical faculty);
• parity with other health professions, most of which have a doctorate as the
credential required for practice;
• enhanced ability to attract individuals to nursing from non-nursing
backgrounds;
• increased supply of faculty for clinical instruction; and
• improved image of nursing.

In addition to interest expressed by these national groups, evidence exists of more local
interest in the markets of the schools that have either initiated a practice doctoral program or
plan to do so. A market analysis survey conducted by the University of Kentucky College of
Nursing prior to opening their DNP program showed that potential employers of these
graduates in that state were very interested in hiring nurses with this level of preparation. In
Fall 1999, a questionnaire was mailed to 382 top executives in acute, long-term, and public
health care settings in Kentucky. A total of 111 responses were received for a response rate
of 29%. Sixty-eight respondents (61%) indicated they would be interested in hiring graduates
of this program and estimated they would have within the next five years a total of 80
positions available for graduates of this program (University of Kentucky College of Nursing,
1999). Examples of the positions for which respondents would hire graduates included
Vice President for Clinical Services, Program Director, Vice President for Patient Care,
Chief Executive Officer, Health Officer or Commissioner, Quality Improvement Director,
Director of Clinical Services, Clinical Information Technology Specialist, Direct Care
Clinician, and Faculty Member.

Recommendation 2: The practice-focused doctoral program be a distinct model of

doctoral education that provides an additional option for attaining a terminal degree in the
discipline.

Recommendation 3: Practice-focused doctoral programs prepare graduates for the

highest level of nursing practice beyond the initial preparation in the discipline5.

This position is consistent with formal action taken in April 2002 by the NONPF Board and
in May 2003 by the CIC deans. The addition of practice-focused doctoral programs should
not threaten enrollment in existing research-focused programs, but rather would fill an unmet
need for nurses who would like to pursue doctoral study, but would prefer to focus on

5
Practice-focused doctoral programs may choose to create multiple entry points and seamless transition from
entry-level preparation to graduation; however, the practice doctoral degree, a terminal degree, should signify
expertise at the highest level of nursing practice.

8
Position Statement on the Practice Doctorate in Nursing

practice rather than research. The two types of programs, research and practice-focused,
would attract students with very different goals and interests.

ISSUES AND CHALLENGES

With increased attention on the practice-focused doctorate that has occurred in recent
months, several issues and challenges have come to light.

Unified Versus Diverse Approach

Among the most difficult issues is whether all programs should adopt a standardized purpose
and set of expected competencies for graduates. Although most stakeholders identify the
desirability of standardization to minimize confusion among prospective students, employers
and the public, there is some disagreement about the form standardization should take. For
example, while some have argued that the practice-focused doctorate should be limited to
those involved in the direct or hands-on clinical care of patients, others have broadened the
definition of advanced nursing practice to include both direct clinical practice and areas of
practice that support clinical practice. Given the complexity of the current health care system,
the current need for advanced practice nursing expertise is broad and encompasses all areas
of advanced nursing practice. Therefore, it is reasonable to endorse a plan that will permit
practice-focused programs to focus on any area of advanced nursing practice that influences
health care outcomes for individuals or populations, while adhering to a consistent set of
standards regarding areas of core content, supporting resources, student qualifications, and
faculty expectations.

A set of broad core competencies would be identified and would be expected of all graduates
holding a practice-focused doctoral degree. Specific competencies for the various domains of
practice and roles for which graduates were being prepared would supplement the core
competencies. A similar model was established with the AACN Essentials of Master’s
Education for Advanced Practice Nursing, which identified three components of master’s
nursing education: graduate nursing core (foundational curriculum content essential for all
students pursuing a master’s degree in nursing regardless of specialty or functional focus);
advanced practice nursing core; and specialty curriculum content (AACN, 1996).

Using this curriculum model, outcome-based competencies would be identified for the core
content areas for all graduates of practice-focused doctoral programs. In addition, outcome-
based competencies for graduates of programs designed to prepare nurses in one of the
advanced nursing practice focus areas (such as advanced direct care practice, care of
populations, leadership, or policy) and specialized competencies would be identified by the
individual specialty areas of practice (e.g., family primary care, psych-mental health, nurse
anesthesia, public health). A validation process similar to that developed by AACN and
NONPF for NP primary care competencies could be used.

9
Position Statement on the Practice Doctorate in Nursing

Recommendation 4: Practice-focused doctoral nursing programs include seven essential

areas of content. The seven essential areas of content include:
1. scientific underpinnings for practice;
2. advanced nursing practice;
3. organization and system leadership/management, quality improvement and
system thinking;
4. analytic methodologies related to the evaluation of practice and the application
of evidence for practice;
5. utilization of technology and information for the improvement and
transformation of healthcare;
6. health policy development, implementation and evaluation; and
7. interdisciplinary collaboration for improving patient and population healthcare
outcomes.

Concurrently and with input from the Task Force on the Clinical Doctorate, the AACN Task
Force on Education & Regulation II developed the Working Paper on the Clinical Nurse
Leader Role (AACN, 2003), which subsequently was accepted by the AACN Board in
October 2003. The development of this new nurse role, Clinical Nurse Leader (CNL), was in
response to growing client care needs and to the changing health care delivery environment.
In February 2004, the AACN Board approved the development of new models of nursing
practice and nursing education at the master’s degree in nursing level that result in a new
nursing professional, the CNL (AACN, 2004). The CNL is a generalist, provides care in all
health care settings at the point of care, and assumes accountability for client care outcomes
by coordinating, delegating, and supervising the care provided by the health care team. The
CNL is not an advanced practice nurse, as defined in this position statement. As the education
of the generalist nurse is elevated to the master’s degree level, it is reasonable to
assume that specialty education and the education of those individuals prepared for the
highest level of nursing practice would occur at the practice doctoral level.

Recommendation 5: Practice doctoral nursing programs should include development

and/or validation of expertise in at least one area of specialized advanced nursing practice.

Expert leadership should be a core component of practice-focused doctoral programs.

Nurses with superb leadership skills at the most advanced clinical and organizational levels
are most likely to be able to identify emerging trends and initiate policy and programmatic
efforts to address critical clinical issues. They should be prepared to mobilize
interdisciplinary teams of clinicians, administrators, policy makers, and members of the
public to solve highly complex clinical problems. It is no longer sufficient to apply clinical,
organizational, or economic skills to the resolution of complex health problems in a singular
fashion. While still much can and should be gained from interdisciplinary teamwork by
experts in each of these areas, the highly integrated health problems faced in the 21st century
will be better served by clinicians who have the creativity and knowledge base to combine
these domains in novel ways to create new models of care delivery. Holders of the practice
doctorate degree in nursing are expected to provide visionary leadership for the practice of
nursing. Practice leadership occurs both formally (by means of administrative or

10
Position Statement on the Practice Doctorate in Nursing

management position title and responsibilities) and informally by means of expertise-based

interactions with colleagues and other health professionals that influence the nature and
quality of care provided. Leadership is not synonymous with an administrative position.

Recommendation 6: Practice-focused doctoral nursing programs prepare leaders for

nursing practice. The practice doctorate prepares individuals at the highest level of
practice and is the terminal practice degree.

Degree Titles

The proliferation of doctoral degree titles in nursing has been recognized as a source of
confusion within and outside of the profession. The general consensus is that the
development of practice-focused doctoral programs should not compound the problem. Two
possibilities exist: 1) identify one degree title for all practice-focused doctoral programs,
acknowledging that programs with the same degree name may differ from one another,
particularly in area of emphasis; or 2) identify two or more degree titles to be used, each with
a specific focus and a high degree of consistency among programs offering the same degree.
For example, programs that prepare individuals for advanced direct care practice (e.g.,
primary care NPs) would confer one degree while programs that prepare individuals for
nursing practice roles in leadership, policy, informatics or community health, would confer a
different degree. Based on input from a variety of stakeholders, the consensus, although not
unanimity, of the Task Force is that it is advisable to simplify and decrease the number of
doctoral degrees offered within the discipline, rather than continuing the proliferation of
degree titles. The degree would represent the highest level of preparation in nursing practice
and would carry with it the understanding that a standard set of competencies had been
attained. However, the more specific competencies associated with a specialty domain of
practice would be validated through a certification process and communicated via a specialty
credential (as is the case with current specialized advanced practice).

One practice doctoral program, already in place, uses the title Doctor of Nursing Practice
(DNP), and another is going through the approval process. If one degree title is chosen, it is
recognized that all programs offering the degree will not be alike and will indeed produce
graduates with somewhat different competencies as defined by the specific track, just as all
master’s programs in nursing do not prepare graduates with the same specialized
competencies.

As described above, the degree title, Doctor of Nursing (ND) currently is conferred by four
institutions. In addition, the degree title of ND, Doctor of Naturopathy, is included in the
Classification of Instruction Programs: 2000 Edition, by the U.S. Department of Education
(2002). This document provides a taxonomic scheme that supports the accurate tracking,
assessment, and reporting of fields of study and program completions activity. In this report,
the discipline of naturopathy claims to have a degree title of ND for those in independent
professional practice of naturopathic medicine. Twelve states currently license naturopathic
physicians.

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Position Statement on the Practice Doctorate in Nursing

The Naprapathy discipline grants individuals the title of DN, Doctor of Naprapathy.
According to the American Naprapathic Association, the degree and license is recognized in
at least three states (American Naprapathic Association, 2004). Naprapathy is an alternative
therapy that focuses on nonpharmacologic pain relief.

It is recognized that institutions confront a variety of issues regarding degree names, and
some may have difficulty changing the degree(s) currently offered for their practice-focused
doctoral programs, e.g., the current ND and DNSc practice-focused doctoral programs.
However, due to the confusion that continues to surround the Doctor of Nursing (ND) degree
and to standardize the degree title conferred by all practice-focused nursing doctoral
programs, the following recommendations are made:

Recommendation 7: One degree title should be chosen to represent practice-focused

doctoral programs that prepare graduates for the highest level of nursing practice.

Recommendation 8: The Doctor of Nursing Practice (DNP) be the degree associated with
practice-focused doctoral nursing education.

Recommendation 9: The Doctor of Nursing (ND) degree title be phased out.

Relationship to Current Advanced Practice Nursing Programs

A new and higher level of preparation for advanced practice nursing is justified if and only if
it results in sufficient knowledge and skill above that already included at the master’s level.
Program content and graduates’ competencies clearly must go beyond those of current
master’s programs. Given the increasing complexity and sophistication of health care, the
Task Force members and stakeholders who provided input to the Task Force were confident
that the additional education is well justified and does represent added value. The specialty
competencies developed for the proposed DrNP graduate (who will be providing direct care
to individuals), for example, “are built upon and expand the competencies of the master’s
prepared nurse practitioner” (Committee on DrNP Competencies, 2003, p.1).

Given the tremendous time, credit and clinical experience required for master’s degree APN
programs6, serious consideration should be given to moving toward the practice doctorate as
the graduate degree for APN preparation. Because a major shift of this kind will not occur in
the immediate future, it will be necessary to provide an extended transition period during
which nurses with master’s degrees would be recognized to be fully credentialed for current
advanced practice roles. A challenge will be to identify, using an evidence-based approach,
the curricular standards associated with both master’s and doctoral APN education and
provide for a seamless interface between educational programs. In addition, after advanced
clinical competencies of the practice doctorate are identified, a standardized method for

6
Advanced Practice Nurses (APNs) is used here to refer to the four direct care roles: certified nurse midwife
(CNM), certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), and nurse practitioner
(NP).

12
Position Statement on the Practice Doctorate in Nursing

validating these competencies should be established. During the transition period, it will be
necessary to ensure multiple entry points into practice-focused doctoral programs. With an
extended transition period and accessible programs, APNs, currently practicing in one of the
four APN roles, who wished to obtain the doctoral degree would be provided the opportunity
to earn a practice doctorate.

Another identified concern is the cost in time and resources, particularly financial resources,
required to upgrade one’s credentials. Other disciplines, e.g., pharmacy, have made a recent
shift from baccalaureate to doctoral preparation for entry into practice and have devised a
variety of approaches to ease the transition. A variety of approaches to ease the transition
should be developed to allow APNs to advance their education and degree title. A final
concern that has been identified is the economic impact of such an educational shift on the
labor market for APNs. This impact should be taken into account as plans are made for the
transition period to ensure a feasible and sustainable shift in educational preparation for
advanced practice nurses. The Task Force believes that the benefits of such a move will
outweigh the costs but recognizes that the transition plan will need to take into account the
timing of costs and benefits.

Recommendation 10: The practice doctorate be the graduate degree for advanced nursing
practice preparation, including but not limited to the four current APN roles: clinical
nurse specialist, nurse anesthetist, nurse midwife, and nurse practitioner.

Recommendation 11: A transition period be planned to provide nurses with master’s

degrees, who wish to obtain the practice doctoral degree, a mechanism to earn a practice
doctorate in a relatively streamlined fashion with credit given for previous graduate study
and practice experience. The transition mechanism should provide multiple points of
entry, standardized validation of competencies, and be time limited.

Preparation for the Clinical Educator and Faculty Roles

A practice-doctoral degree in nursing would prepare nurses with advanced preparation and
specialized knowledge in one identified area of nursing practice. The discipline of education
encompasses an entirely separate body of knowledge and competence. Many nursing practice
doctoral graduates may choose the educator role. Graduates of practice doctoral programs
will have expertise and preparation for the highest level of nursing practice. Preparation to
teach at the collegiate level, as in other disciplines, requires preparation with a terminal
degree. However, just as for graduates of research-focused doctoral programs, graduates of
practice-focused nursing programs may need additional education in the educator role and
pedagogical methodologies (AACN, 2001).

Recommendation 12: Practice doctorate programs, as in research-focused doctoral

programs, are encouraged to offer additional coursework and practica that would prepare
graduates to fill the role of nurse educator.

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Position Statement on the Practice Doctorate in Nursing

Accreditation and Regulation

Accreditation and regulation are complex issues. The quality of research-focused doctoral
programs is ensured through ongoing review and quality assessment, which are generally
carried out by the graduate school (or comparable entity) of the offering institution. Practice-
focused doctoral programs, like master’s programs, prepare graduates for specialized
professional practice that is regulated by agencies charged with protecting the safety of the
public. The quality of practice-focused doctoral programs, their ability to produce graduates
with the requisite competencies for advanced practice, and their adherence to high standards
of professional education must be scrutinized and ensured by professional nursing
accrediting bodies.

It also is recognized that a change in the educational requirements for APN practice could
impact certification and regulation. Stakeholders representing certifying and regulatory
bodies, however, have indicated that the specific impact and need for change in these arenas
cannot be identified at this point in the transition phase. These individuals further indicate
that, as outcome-based competencies are identified and programs evolve, certification and
regulatory changes will follow.

Recommendation 13: Practice-focused doctoral programs need to be accredited by a

nursing accrediting agency recognized by the U.S. Secretary of Education.

SUMMARY OF RECOMMENDATIONS

The Task Force recommends:

1: The term practice doctorate be used instead of clinical doctorate.

2: The practice-focused doctoral program be a distinct model of doctoral education that

provides an additional option for attaining a terminal degree in the discipline.

3: Practice-focused doctoral programs prepare graduates for the highest level of nursing
practice beyond the initial preparation in the discipline.

4: Practice-focused doctoral nursing programs include seven essential areas of content. The
seven essential areas of content include:
1. scientific underpinnings for practice;
2. advanced nursing practice;
3. organization and system leadership/management, quality improvement and
system thinking;
4. analytic methodologies related to the evaluation of practice and the application of
evidence for practice;
5. utilization of technology and information for the improvement and transformation
of healthcare;
6. health policy development, implementation and evaluation; and

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 Position Statement on the Practice Doctorate in Nursing

7. interdisciplinary collaboration for improving patient and population healthcare

outcomes.

5: Practice doctoral nursing programs include development and/or validation of expertise in

one area of specialized advanced nursing practice.

6: Practice-focused doctoral nursing programs prepare leaders for nursing practice. The
practice doctorate prepares individuals at the highest level of practice and is the terminal
practice degree.

7: One degree title be chosen to represent practice-focused doctoral programs that prepare
graduates for the highest level of nursing practice.

8: The Doctor of Nursing Practice (DNP) be the degree associated with practice-focused
doctoral nursing education.

9: The Doctor of Nursing (ND) degree title be phased out.

10: The practice doctorate be the graduate degree for advanced nursing practice preparation,
including but not limited to the four current APN roles: clinical nurse specialist, nurse
anesthetist, nurse midwife, and nurse practitioner.

11: A transition period be planned to provide nurses with master’s degrees, who wish to
obtain the practice doctoral degree, a mechanism to earn a practice doctorate in a
relatively streamlined fashion with credit given for previous graduate study and practice
experience. The transition mechanism should provide multiple points of entry,
standardized validation of competencies, and be time limited.

12: Practice doctorate programs, as in research-focused doctoral programs, are encouraged to

offer additional coursework and practica that would prepare graduates to fill the role of
nurse educator.

13: Practice-focused doctoral programs need to be accredited by a nursing accrediting agency

recognized by the U.S. Secretary of Education (i.e., the Commission on Collegiate
Nursing Education or the National League for Nursing Accrediting Commission).

RECOMMENDED NEXT STEPS

1. A document should be developed that defines:

• Educational standards,
• Indicators of quality for practice doctoral programs, and
• Educational outcomes/competencies.

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Position Statement on the Practice Doctorate in Nursing

1A. The seven areas of core content for all graduates of practice-doctorate nursing
programs have been identified. The outcome-based competencies for each of the
seven core content areas should be identified. A process and outcome similar to that
of the Essentials of Master’s Education for Advanced Practice Nursing (AACN,
1996) should be developed and implemented. The outcome of this process would be
to identify the core outcome competencies expected of graduates of practice doctoral
programs in nursing.

1B. Specialty competencies/essential content should be developed for individual

areas of advanced nursing practice

2. The appropriate preparation and competencies for the clinical educator and faculty
roles should be identified by the AACN Task Force on the Professoriate. Practice-
doctorate programs, based on the recommendations of that Task Force, could then
offer additional coursework and practica, which would adequately prepare graduates
to fill the role of nurse educator.

3. Additional work must be done to identify the implications of these recommendations

and issues related to full implementation, e.g. moving all APN education to the
practice doctoral level, impact on schools, implications for certification and licensure.

4. An interprofessional work group should be formed to examine the potential outcomes

resulting from employment of DNP graduates in health care settings. Topics to be
examined include: cost-effectiveness, impact on processes and outcomes of care, and
priority areas for utilization.

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Position Statement on the Practice Doctorate in Nursing

TASK FORCE ON THE PRACTICE DOCTORATE IN NURSING

Elizabeth Lenz, Chairperson

The Ohio State University

Kathleen Andreoli
Rush University

Jean Bartels, TFER2 liaison

Georgia Southern University

Catherine Gilliss
Yale University

Sandra Edwardson
University of Minnesota

Judy Honig
Columbia University

Lucy Marion, NONPF consultant

University of Illinois, Chicago

Lynne Pearcey
University of North Carolina, Greensboro

Julie Sebastian
University of Kentucky

Marita Titler
University of Iowa Hospitals and Clinics

Joan Stanley, Staff liaison

American Association of Colleges of Nursing

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Position Statement on the Practice Doctorate in Nursing

REFERENCES

American Association of Colleges of Nursing. (2004). Education models to prepare the

clinical nurse leader.
[Link]

American Association of Colleges of Nursing. (2003). Working paper on the role of the
clinical nurse leader. Accessed June 23, 2004 at
[Link]

American Association of Colleges of Nursing. (2001). Position statement on quality

indicators for doctoral programs. Washington, DC: Author.

American Association of Colleges of Nursing. (1996). The essentials of master’s

education for advanced practice nursing. Washington, DC: Author.

American Association of Colleges of Nursing & National Organization of Nurse

Practitioner Faculties. (2002). Master’s-level nurse practitioner educational
programs. Findings from the 2000-2001 collaborative curriculum survey.
Washington, DC: AACN.

American Naprapathic Association. (2004). Naprapath directory. Retrieved March 11,

2004 from [Link]

Bellack, J., Graber, D., O’Neil, E., Musham, C., & Lancaster, C. (1999). Curriculum
trends in nurse practitioner programs: Current and ideal. Journal of Professional
Nursing, 15:15-27.

Committee on DrNP Competencies. (2003). Competencies for a doctor of clinical

nursing. New York, NY: Columbia University School of Nursing.

Institute of Medicine. (1999). To Err is human: Building a safer health system.

Washington, DC: National Academy Press.

Institute of Medicine. (2001). Crossing the quality chasm. Washington, DC: National
Academy Press.

Institute of Medicine. (2003a). Health professions education: A bridge to quality.

Washington, DC: The National Academies Press.

Institute of Medicine. (2003b). Keeping patients safe: Transforming the work

environment of nurses. Washington, DC: The National Academies Press.

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Position Statement on the Practice Doctorate in Nursing

Lenz, E.R., Mundinger, M.O., Hopkins, S., Clark, J., & Lin, S. (September, 2002).
Patterns of nurse practitioner practice: Results from a national survey. Presented
at the State of the Science Conference, Washington, DC. (Unpublished data).

Marion L., Viens D, O’Sullivan A., Crabtree C., Fontana S., & Price M. (2003). The
practice doctorate in nursing: Future or fringe? Medscape
([Link]

Task Force on the Professional Clinical Doctorate. (2002). Survey and telephone
interviews conducted by task force members. Unpublished data. Washington, DC:
American Association of Colleges of Nursing

U. S. Department of Education, National Center for Education Statistics. (2002).

Classification of Instructional Programs-2000: (NCES 2002-165). Washington,
DC: U.S. Government Printing Office.

University of Kentucky College of Nursing. (1999). Survey of nurse executives

Unpublished data. Lexington, KY: Author.

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Position Statement on the Practice Doctorate in Nursing

APPENDIX A

EXTERNAL REACTION PANEL

ON THE AACN PRACTICE DOCTORATE POSITION STATEMENT
February 4, 2004

Merilyn Francis, Assistant VicePresident

National Quality Forum

Ann Greiner, Independent Consultant

National Academy of Sciences

Karen Haase-Herrick, President

American Organization of Nurse Executives

Donald Hagen, Executive Vice Chancellor

Association of Academic Health Centers

Cathy Rick, Chief Officer, Office of Nursing Services

Department of Veterans Affairs

Barbara Safriet, Associate Dean

Yale University Law School

Les Sims, Senior Scholar in Residence and

Director, External Grants Programs
Council of Graduate Schools
(provided written response)

Michael Whitcomb, Senior Vice President

Association of American Medical Colleges

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