EDUCATION
Preparing practice scholars: Teaching knowledge application in the Doctor of Nursing Practice Curriculum Susan Weber Buchholz, PhD, ANP-BC (Associate Professor)1 , Geraldine M. Budd, PhD, FNP-BC, FAANP (Associate Professor)2 , Maureen R. Courtney, PhD, FNP-BC (Associate Professor)3 , Mary B. Neiheisel, EdD, CNS-BC, FNP-BC, FAANP (Professor)4 , Margaret Hammersla, MS, CRNP (Assistant Professor)5 , & Elizabeth D. Carlson, PhD, MPH, APRN-BC (Assistant Professor)6 1
College of Nursing, Rush University Medical Center, Chicago, Illinois School of Nursing, Widener University, Chester, Pennsylvania 3 College of Nursing, The University of Texas Arlington, Arlington, Texas 4 College of Nursing and Allied Health Professions, The University of Louisiana at Lafayette, Lafayette, Louisiana 5 School of Nursing, University of Maryland, Baltimore, Maryland 6 Mennonite College of Nursing, Illinois State University, Normal, Illinois 2
Keywords Education; program development; research; statistics. Correspondence Susan Buchholz, PhD, ANP-BC, College of Nursing, Rush University Medical Center, 600 S. Paulina Street, Chicago, IL 60612. Tel: 312-563-3590; Fax: 312-942-3038; E-mail: [email protected] Received: September 2012; accepted: January 2013 doi: 10.1002/2327-6924.12050
Abstract Purpose: The purpose of this article is to explore the scholarship role of the Doctor of Nursing Practice (DNP) and the associated knowledge and skills required for success. Data sources: There are excellent competencies provided by national organizations that present guidelines for design and application of this practice scholar’s contributions. Although evidence-based research translation is known to be essential for the DNP scholar, a consensus does not exist about the required research knowledge and skill levels that are needed. Conclusions: A model was developed to depict the scholarship roles of the DNP and the Doctor of Philosophy (PhD). This model indicates both DNP and PhD scholars are alike in their enactment of active scholarship but have different areas of expertise. They are different in their major roles that lead to the development of practice science; the DNP is the expert in knowledge application while the PhD is the expert in knowledge generation. Implications for practice: A nurse practice scholar needs to have a fundamental and strong understanding of research design and interpretation in order to appraise and implement research-based evidence into practice and conduct clinical projects.
Practice scholars: DNP knowledge, skills, and roles for scholarship The nursing profession urgently needs professionals with knowledge to support the delivery of safe, cost efficient, evidence-based quality health care. It is fortuitous that a new nursing role, the Doctor of Nursing Practice (DNP), has appeared at this time of great healthcare need (Sperhac & Clinton, 2008). The knowledge base required by DNP-prepared nurses is such that DNP scholars are able to provide expert consultation and judgment on practice issues to support the best possible patient care (American Association of Colleges of Nursing, 2006b). It is necessary that DNP students become experts in using
the widest possible array of resources in their efforts to translate and build evidence-based health care. DNP graduates are prepared to become leaders in the clinical realm. Few deny the need for additional nursing expertise to increase the quality of health care. However, the scholarship dimension of the DNP role has resulted in many questions as to its scope, rigor, fundamental nature, and purpose. Faculty with the PhD degree and others seek clarification of the DNP role in scholarship and research. Although evidence-based research translation is known to be essential for the DNP scholar, a consensus does not exist about the required research knowledge and skills that are needed for achievement. The purpose of this article is to explore the nature of DNP scholarship
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needed for practice. The specific aims are to discuss the history of research and the DNP role; present a model that depicts the scope of DNP scholarship and compare this to the well-known PhD role; describe the specific and necessary DNP skills for achieving research competencies; and recognize that, together, DNP and PhD colleagues can create seamless systems of evidence-based care to achieve desired patient outcomes.
DNP competencies for clinical scholarship Included in pressing healthcare concerns of this century is an aging and more diverse population than ever before seen, an information explosion that entails rapidly changing technology, and a demand for excellent and increasingly complex health care. These continual intellectual, technological, and physical advancements and changes in our society necessitate updates and progress in the education of all healthcare providers. Nurses, the largest group of healthcare providers, have long been concerned about the many pressing issues influencing health care (American Nurses Association, 2012). In order to address the many facets of complex health care, nurses at the baccalaureate level are provided with a basic understanding of the research process and how to use reliable evidence to inform their practice (American Association of Colleges of Nursing, 2008). This basic empirical knowledge provides a foundation for nurses who pursue masters’ degrees and are taught not only how to continue to use current evidence in practice but also to identify healthcare knowledge gaps. Master’s prepared nurses apply outcomes derived from research to resolve problems encountered in practice and disseminate those results in order to advance clinical practice (American Association of Colleges of Nursing, 2011). However, the critical and collective healthcare issues facing the nation have resulted in a call for more nurses with advanced educational preparation beyond the master’s degree level. The American Association of Colleges of Nursing voted to endorse programs granting a DNP degree with the goal of improving the systems affecting individual healthcare delivery (American Association of Colleges of Nursing, 2004). Echoing the American Association of Colleges of Nursing, the National Academy of Science stated “The need for doctorally prepared practitioners and clinical faculty would be met if nursing could develop a new non-research clinical doctorate, similar to the M.D. and Pharm. D. in medicine and pharmacy, respectively” (National Research Council of the National Academies, 2005, p. 74). In the ensuing years, several nursing organizations, including the American Association of Colleges of Nursing, American Nurses Association, and National Or474
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ganization of Nurse Practitioner Faculties developed and published both the conceptualizations of the nursing doctorate degree and the competencies needed for practice at this advanced level (American Association of Colleges of Nursing, 2012b; American Nurses Association, 2011; National Organization of Nurse Practitioner Faculties, 2006). The ability to critically analyze data that are used to translate evidence-based knowledge into practice settings is important to each of these organizations. Universities throughout the United States have developed curricula using the competencies detailed by nursing’s various governing bodies. The number of DNP programs is increasing rapidly. In 2006, there were only 20 DNP programs and there are now over 180 DNP programs in the United States (American Association of Colleges of Nursing, 2012a, 2012b). Providing specific and detailed information about how to operationalize the research competencies necessary for DNP curriculum is important.
A model for practice and research scholarship DNP programs are preparing graduates to be able to practice at the highest level in multiple clinical settings, leading the way in the application and translation of disseminating successful research findings into practice. PhD programs are preparing graduates to become leaders in conducting scientific research, to advance empirical knowledge that can be utilized to improve health outcomes for people across the life span (Rush University, 2012; The John Hopkins University School of Nursing, 2012; The University of Iowa, 2012; University of Washington, 2012). A model was developed to depict the scholarship activities of the DNP and the PhD graduates (Figure 1), which indicates both DNP and PhD scholars are alike in their enactment of active scholarship but have different areas of expertise. They are different in the major activities undertaken that lead to the development of practice science. The DNP curriculum approach focuses on expertise in knowledge application, while the PhD curriculum approach centers on expertise in knowledge generation. In general, the DNP scholar’s expertise is in the areas of evidence appraisal and research synthesis, using rigorously developed skills. The DNP scholar is accountable as a clinical leader to translate research to unique clinical settings and populations, including implementing interventions, evaluating outcomes, and integrating best practices that have been verified by research and thus making contributions to the cycle of evidence-based practice (American Association of Colleges of Nursing, 2004). In a complementary fashion, the PhD graduate’s expertise as a scholar is through independent, original research conducted to describe, explain, predict, and, ultimately
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Research Scholar
Practice Scholar
Both are full scholars, emphasis is different
Knowledge Application
Appraisal Research Synthesis Translation Implementation Evaluation Integration
Knowledge Generation
EBP Enrichment Cycle
Independent Research of Phenomena: Description Explanation Prediction Control
PhD
DNP
Courtney, 2011 Figure 1 A model for practice and research scholarship.
control phenomena of concern to nursing. Expert knowledge generation is the PhD specialist’s contribution to the cycle of evidence-based practice (American Association of Colleges of Nursing, 2006a). The scholarship dimension of either doctoral role is incomplete without the other. Knowledge generation alone is insufficient in a practice discipline; without careful translation it will not serve patients. Likewise, one cannot apply knowledge to practice that does not have sufficient validity and reliability produced through the efforts of nursing’s research scholars. Only in collaboration, can the DNP and PhD scholars create and weave the body of clinical knowledge required to achieve desired patient outcomes. It is important to note that the authors and others (Vincent, Johnson, Velasquex, & Rigney, 2010) acknowledge that occasional overlap in these areas of expertise and activity will occur between the two roles. The DNP-prepared nurse uses skills of evidence appraisal and research synthesis as identified in the model. These are the most well-known skills associated with the role and fundamental to the DNP scholar’s contribution to clinical practice. The specific aspects of these areas will be discussed in a later section. The DNP graduate provides leadership to translation of knowledge to the clinical setting. The DNP-prepared nurse must analyze the appropriateness of specific knowledge to be translated to a specific setting. This entails consideration of the patient population, staffing, administrative resources, openness to change, and other unique factors in a given setting. If evidence is judged ready for
translation to the setting, a detailed implementation plan must be developed. After that interventions that have been implemented for a specific patient population and setting must be carefully evaluated to determine applicability to the chosen clinical environment. Evaluation questions that the DNP scholar must pursue include the degree of commitment and fidelity with which staff implement an intervention and specific patient outcomes for those receiving the intervention in the designated setting (Courtney & Neiheisel, 2011). This evaluation of the validity of research evidence used in the DNP-prepared nurse’s setting is required to determine the effectiveness of the knowledge translation. When interventions have been positively evaluated in the DNP-prepared nurse’s setting, leadership by the DNP is required to successfully integrate care approaches into the system. The DNP scholar can assist to maintain a continuously evolving care setting that integrates the most effective and efficient clinical practice. These are the DNP scholar’s activities that contribute to the cycle of evidence-based practice. The PhD-prepared nurse’s expertise as a scholar is through independent, original research to create, replicate, and/or extend knowledge. This requires expertise in knowledge of relevant theory, research methodologies, and statistical analysis. In addition, topics for knowledge generation for the PhD student and graduate should be formed by high-value clinical practice questions, often identified by the DNP. The model (Figure 1) depicts the strengths and skills of both scholar roles and shows that it is through a balance of their respective areas of expertise that the evidencebased enrichment cycle is achieved. Nursing and patients benefit from the collaborative scholarship contributions of both roles (Edwardson, 2010).
Organizing a knowledge application framework for the practice scholar The development and application of research and evidence will take a different focus for the DNP-prepared nurse when compared to the PhD-prepared nurse. A set of essential skills is needed for all doctorally prepared nurses who engage in clinical scholarship. For DNP students, the goal is knowledge application, which requires mastery of a significant body of research intended to support this function. The foundational knowledge needed to provide the highest standard of patient care includes appraisal, research synthesis, translation, implementation, evaluation, and integration. Inherent in these steps is an expertise in understanding and interpreting research findings so that the skills can be used to understand the existing evidence and to design and implement 475
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processes to evaluate related outcomes. A thorough understanding of this knowledge will enable DNP students to enhance quality improvement and to participate in practice-related research as needed (American Association of Colleges of Nursing, 2006b).
Skills for appraisal of the evidence Developing a precisely formulated clinical question is the foundation for completing a thorough literature search of available evidence. This is an integral research competency for all doctoral students. DNP students must demonstrate the necessary skills to consistently and thoroughly evaluate evidence on a given topic so as to make positive practice changes and promote the highest level of care. Each integral step in the literature review process needs to be achieved. A successful literature examination begins with a calculated search strategy. Knowing which key words to use, how to use the combinations of key words that are most accurate and will produce the greatest yield, how to use Boolean operators, and how to use a multitude of databases will allow students to very efficiently search the literature (Levy & Ellis, 2006). This skill set may be used for an integrated literature review or a systematic review, but just as likely it may be used to find key articles to implement patient or system change in healthcare settings. An integral point in the successful literature search is using available resources. Helping DNP students establish early working relationships with information specialists in the university or hospital provides DNP students with strong search allies (Scherrer & Dorsch, 1999). When the literature is appraised, DNP students must learn to quickly decipher several components. First, literature must be deemed to be not only accurate, but from a high-quality source and an original citation. Second, research studies must be judged to be relevant to what is needed and also be found important to the broader stakeholders involved. Third, literature must be applicable to the clinical question (Fineout-Overholt, Melnyk, Stillwell, & Williamson, 2010). The following sections outline critical research knowledge and skill development for the DNP student. These include development of a high-level literature review and analysis, development of evidence-based practice and clinical outcomes, and research methodology and procedure proficiency.
Systematic reviews and expert content Systematic reviews are one form of secondary research that students will examine and produce. DNP students should be able to determine overall factors that make for a strong systematic review and be able to evaluate 476
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specifics of each research study included in a systematic review. DNP students must examine each of the studies included in systematic reviews of quantitative research for validity. They must be conversant with the Cochrane Collaboration and specific Cochrane Reviews, and must understand the Cochrane’s guidelines for reviewing and reporting results of randomized controlled trials, systematic reviews, and meta-analyses. Carefully reviewing how each of the authors came to conclusions, and the specific processes used, is critical to appraising the overall rigor of any systematic review and is best guided by sources, such as the Cochrane Handbook (Higgins & Green, 2011). Engaging in the process of conducting a systematic review allows the student to better learn its process and components. While graduates should never conduct this type of review without a team, it can be a quite useful learning experience for students and results in their developing skill in searches and evidence appraisal. Many students use the understanding they have gained from conducting their own systematic review as the basis for designing their scholarship projects. The review of specific research reports should follow the standards identified by the Cochrane Collaboration. For randomized controlled trials the Consolidated Standards for Reporting Trials (CONSORT; Hopewell et al., 2008; Schulz, Altman, & Moher, 2010) is the accepted guide. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) provides procedures on reporting and reviewing systematic reviews and meta-analyses (Moher, Liberati, Tetzlaff, Altman, & The PRISMA GROUP, 2009). Consistent and skillful use of the available resources will aid students in understanding research findings and in further establishing evidence-based use implications of systematic reviews. The most demanding standard of systematic review is the statistically performed meta-analysis of multiple research studies. The results of a meta-analysis are presented by the type of data used to formulate the results. This level of analysis is often prohibited because of studies using different variables and statistical procedures. Therefore, a critical skill for assessing systematic reviews is the analysis for heterogeneity of the data and assessing which strategies are employed to manage a dilemma with lack of heterogeneity. Differentiation between use of dichotomous data or continuous data is a useful skill. Interpretation of effect size, forest plots, confidence intervals, and p values will aid in deciding if the systematic review is worthwhile to use in changing clinical practice (Thomas, Ciliska, Dobbins, & Micucci, 2004; Zlowodzki, Poolman, Kerkhoff, Tornetta, & Bhandari, 2007). The utilization of qualitative data is becoming increasingly more prominent in understanding how to realistically implement practice-based evidence in the clinical
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and community setting (Leeman & Sandelowski, 2012). Utilization of qualitative metasummary as well as qualitative metasynthesis are useful for the interpretation of qualitative systematic reviews (Cohen & Crabtree, 2008) Qualitative metasummary provides a method to aggregate qualitative findings, and can be used when mixed research syntheses are needed to answer important clinical questions (Sandelowski, Barroso, & Voils, 2007). Metasynthesis is particularly useful when trying to determine the feasibility, appropriateness, and meaningfulness of a health-related question (Joanna Briggs Institute, 2012). In all systematic reviews, it is imperative to assess the question and the methodology chosen to answer the question and to ask how the data were extracted, coded, pooled into categories, and ultimately synthesized.
Evidence-based practice and clinical outcomes For evidence-based practice, there are many national and international resources that can be used by DNP students. Appraisal tools that are useful for DNP students exist beyond appraising systematic reviews and randomized control trials. The Critical Appraisal Skills Program (CASP) tools provide a way to critically appraise qualitative research, economic evaluation studies, cohort studies, case–control studies, and diagnostic test studies (Critical Appraisal Skills Programme, 2011). Narrative and thematic content also can be examined systematically (Mays, Pope, & Popay, 2005). The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument is a frequently used tool for evaluating consensus guidelines (The AGREE Collaboration, 2001). The six quality domains in the AGREE instrument are “i) scope and purpose; ii) stakeholder involvement; iii) rigour of development; iv) clarity of presentation; v) applicability; and vi) editorial independence” (AGREE Enterprise, 2010). DNP students need to be able to quickly interpret the level of evidence, which is the hierarchy of study evidence. Typically, systematic reviews are at the highest level. When evaluating research, it is important to ask the question ”what is the level of the research” (Oxford Centre for Evidence-based Medicine, 2009). DNP students must be instructed to ask about the strength of recommendations and if the evidence is strong enough to recommend using an intervention (Ebell et al., 2004). By understanding level of evidence and strengths of recommendations, DNP graduates can provide sound advice for implementing changes. Evidence-based practice is informed by the best available evidence, clinical expertise, patient values and preferences, and available resources (Melnyk & Fineout-Overholt, 2010). Being able to integrate these typically uneven aspects of evidence-based
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practice requires integrating statistical knowledge, systematic review, expert content, and clinical experience.
Research methodology proficiency Evaluating and translating research requires proficiency of understanding research to accurately interpret other study analyses or research synthesis. In addition, it may be that DNP students will undertake a project that is research-based and thus, need to plan a study themselves. DNP curriculum developers may take multiple approaches in providing guidelines that facilitate choosing an appropriate research questions. One approach that Cochrane takes to asking an answerable question is the “PICOT” question (Cochrane Public Health Group, 2012). The “PICOT” question is a time-tested method of unraveling a research question down to the components that it is representing. “P” represents the patient population of interest. “I” represents the intervention or area of interest in the study. “C” represents the comparison or control to the intervention. “O” represents the outcome of the study and “T” represents the time frame of the study. The PICOT question provides a framework that can be easily used when retrieving the literature (Facchiano & Snyder, 2012; Richardson, Wilson, Nishikawa, & Hayward, 1995; Thabane, Thomas, Ye, & Paul, 2009). Variable identification and level of measurement identification are essential components of research. Assuring that DNP students can correctly identify the variables is critical; the independent variable, the variable of manipulation, and a dependent variable must all be identifiable. In the case where a research study does not have an independent variable and a dependent variable, then helping students identify the phenomenon of interest is important (Polit & Beck, 2008). Identifying if the study uses nominal or discrete data, ordinal or rank-ordered data, interval or continuous order data, or a combination of these measures is likewise important. When DNP students develop their own projects, they should use the highest order of data as possible so as to produce the most thorough results (Polit & Beck, 2008). Guiding DNP students to understand psychometric properties, particularly in relation to tools or instruments, is essential for several reasons. Choosing instruments that correctly and consistently measure an identified concept is critical for assuring study validity (Polit & Beck, 2008). Using reliable instruments and being able to determine if stability, internal consistency, and/or equivalence is being assessed is important not only for an individual project, but also for evaluating if completed research is replicable and translatable. Being able to understand, if statistical conclusion validity, the multiply construed construct validity, internal validity, or external validity is being assessed, is 477
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important in understanding if an instrument has been designed correctly. Assessment of instrument feasibility, including type of measures, length, cost, language, literacy, and ease of use will help to determine its appropriateness for use. Standard research texts emphasize these properties so that the participant does not become overburdened (Polit & Beck, 2008). While in the social sciences, reliability and validity have been used as concepts for examining terms used to define the rigor of qualitative research, evaluating trustworthiness of a qualitative study is important to determining worth. Establishing if qualitative research has trustworthiness involves understanding study credibility, transferability, dependability, and confirmability (Lincoln & Guba, 1985). Strong qualitative research is ethical, important, clear, and credible. In addition it can be verified; uses appropriate arduous methods; assesses for reflexivity; and provides guidance in utilizing strong qualitative research to guide clinical decision making (Cohen & Crabtree, 2008).
Research procedure proficiency DNP projects can use a quantitative nonrandomized preexperimental (pre–post) design. However, when the research question is appropriate, advisors can guide DNP students to consider a quasi-experimental or randomized control experimental design. This will require a little more effort but the answers to clinical questions will have greater validity. It is recognized that not all DNP projects will involve evaluation of an intervention. With qualitative DNP work, the DNP students need two key factors in place. The first is a methodology that is appropriate for the question; the second is a faculty member experienced with that type of methodology, whether it is focus groups, grounded theory, phenomenology, ethnography or other qualitative methodology (Polit & Beck, 2008). For both quantitative and qualitative research projects, students will need both access and faculty to help them with the use of scientific data analysis software. Being grounded in descriptive statistics is useful, so doctorally prepared nurses have a fundamental level of knowledge as they translate scientific findings into the practice setting (American Association of Colleges of Nursing, 2006a). The level of inferential statistical knowledge that is needed is dependent on the design needed to answer the clinical question(s) encountered in the future. This is arguably one of the areas of greatest difference between DNP students and PhD students. A high-level understanding of complex inferential statistics is likely not necessary for DNP students. Without a fundamental understanding of inferential statistics, DNP students will struggle to understand how to analyze and interpret their 478
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findings and, equally important, the findings of other authors that they will read and review to guide their practice when they are graduates. DNP scholars make critical contributions to providing the highest quality patient care possible. To assist them to do this, multiple tools and resources are available. For example, Standards for Quality Improvement Reporting Excellence (SQUIRE) is an effective tool for evaluation of quality improvement projects (SQUIRE, 2008). The expected outcome of exposure to this research information is to allow DNP students to work with the clinical situation and setting at hand along with the patients and caregivers who are already in place, so as to provide the best evidence-based practice client-centered care possible.
Moving the research forward as a DNP Translational research is taking an ever-increasing place in today’s healthcare research landscape. This is demonstrated by the National Institutes of Health’s Clinical and Translational Science Award program that was launched in 2006. Currently there are two basic forms of translational research. The first being the idea of “bench-tobedside” research that is the purposeful practice of ensuring that new treatments and knowledge benefit the population for which they were intended (T1). The second aims to reduce the gap between knowledge and practice while obtaining improved quality of care (T2; Woolf, 2008). The Institute of Medicine’s Clinical Research Roundtable further differentiates these two forms of translational research. T1 involves understanding how disease mechanisms that have been described at the bench can provide new methods for diagnosis, therapy, and prevention. T2 seeks to move these new methods beyond clinical trials/studies and into everyday clinical practice (Sung et al., 2003). Implementation science is a specific form of T2 research. Implementation science directly impacts the ability to improve both quality and effectiveness of healthcare delivery services by using rigorous scientific methods that include clinical research findings and additional evidence-based practice knowledge (Eccles, 2006). Implementation science, while clearly important for moving effective programs into everyday practice, continues to face challenges, and is an area ripe for DNP and PhD scholars to provide significant impact at the ground level of healthcare changes in multiple settings (Irwin & Supplee, 2012), It is clear that DNP students are poised to lead the movement of translational and implementation research. DNP students will need to have a strong foundation of research design and statistical analysis as described earlier. Although outside the scope of this article, an understanding of organizational theory and health policy, coupled
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with a strong research base, is necessary. Having knowledge in these additional areas will help to facilitate the development of expert clinicians with the expertise to evaluate not only the literature, but how to realistically implement and manage practice change on an organizational scale.
Conclusion Debate about how much and what type of research knowledge is needed for DNP students has resulted in considerable discussion for curriculum committees in many schools and colleges of nursing. There are excellent competencies provided by national organizations that present guidelines for design and application of this practice scholar knowledge. However, the general research knowledge base for DNP students depends in part on how much of a research and statistical base is envisioned by a curriculum committee, as being needed for the DNP scholar to fully appraise the evidence and realistically implement evidence-based programs and solutions to ongoing challenges and difficult problems in the healthcare realm. This article makes the argument that a nurse practice scholar needs to have a fundamental and strong understanding of quantitative and qualitative research design and interpretation to implement researchbased projects into practice. Given the egalitarian natures of the DNP and PhD roles, it is important to keep in mind from a curricular perspective, the knowledge that is needed to maximize what the DNP-prepared nurse and the PhD-prepared nurse each require as they work together to provide optimal health care. If scholarly biases exist between DNP and PhD scholars, then these biases need to be set aside in order to provide panoramic opportunities to improve health outcomes. Individuals and populations across the life span stand the most to gain when DNP and PhD scholars work together with mutual respect as they address the critical healthcare needs of our nation.
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Melnyk, B. M., & Fineout-Overholt, E. (2010). Evidence-based practice in nursing and healthcare: A guide to best practice (2nd ed.). Philadelphia, PA: Lippincott, Williams & Wilkins. Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & The PRISMA GROUP. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLOS Medicine, 6(7), 1–6. doi: 10.1371/journal.pmed.1000097 National Organization of Nurse Practitioner Faculties. (2006). Practice doctorate nurse practitioner entry-level competencies. Retrieved from http://www. nonpf. com/associations/10789/files/DNP%20NP%20competenciesApril2006.pdf National Research Council of the National Academies. (2005). Advancing the nation’s health needs. Washington, DC: National Academies Press. Oxford Centre for Evidence-based Medicine. (2009). Oxford centre for evidence-based medicine—levels of evidence. Retrieved from http://www. cebm.net/index.aspx?o=1025 Polit, D. F., & Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice (8th ed.). Philadelphia, PA: Lippincott Williams and Wilkins. Richardson, W. S., Wilson, M. C., Nishikawa, J., & Hayward, R. S. (1995). The well-built clinical question: A key to evidence-based decisions. American College of Physicians Journal Club, 123(3), A12–3. Rush University. (2012). Rush University College of Nursing degree and certificate options. Retrieved from http://www.rushu.rush.edu/servlet/ Satellite?c=RushUnivLevel2Page&cid=1221491470093&pagename= Rush%2FRushUnivLevel2Page%2FLevel 2 College GME CME Page Sandelowski, M., Barroso, J., & Voils, C. (2007). Using qualitative metasummary to synthesize qualitative and quantitative descriptive findings. Research in Nursing Health, 30(1), 99–111. doi:10.1002/nur.20176 Scherrer, C. S., & Dorsch, J. L. (1999). The evolving role of the librarian in evidence-based medicine. Bulletin of the Medical Library Association, 87(3), 322–328. Schulz, K., Altman, D., & Moher, D. (2010). CONSORT 2010 statement: Updated guidelines for reporting parallel group randomised trials. BMC Medicine, 8, 18–18. doi:10.1186/1741–7015–8–18 Sperhac, A., & Clinton, P. (2008). Doctorate of nursing practice: Blueprint for excellence. Journal of Pediatric Health Care, 22(3), 146–151. doi:10.1016/j.pedhc.2007.12.015
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SQUIRE. (2008). SQUIRE guidelines. Retrieved from https://docs.google. com/viewer?url=http%3A%2F%2Fwww.squire-statement.org% 2Fassets%2Fpdfs%2FSQUIRE˙guidelines˙table.pdf Sung, N., Crowley, W., Genel, M., Salber, P., Sandy, L., Sherwood, L., . . . Rimoin, D. (2003). Central challenges facing the national clinical research enterprise. Journal of the American Medical Association, 289(10), 1278– 1287. Thabane, L., Thomas, T., Ye, C., & Paul, J. (2009). Posing the research question: Not so simple. Canadian Journal of Anesthesia, 56(1), 71–79. doi:10.1007/s12630-008-9007-4 The AGREE Collaboration. (2001). Appraisal of guidelines for research and evaluation. Retrieved from https://docs.google.com/viewer?url= http%3A%2F%2Fwww.agreecollaboration.org%2Fpdf% 2Fagreeinstrumentfinal.pdf The John Hopkins University School of Nursing. (2012). John Hopkins University School of Nursing doctoral programs. Retrieved from http://nursing. jhu.edu/academics/programs/doctoral/index.html The University of Iowa. (2012). The University of Iowa College of Nursing academic programs. Retrieved from http://www.nursing.uiowa.edu/academicprograms Thomas, B. H., Ciliska, D., Dobbins, M., & Micucci, S. (2004). A process for systematically reviewing the literature: Providing the research evidence for public health nursing interventions. Worldviews on Evidence-Based Nursing, 1(3), 176–184. doi:10.1111/j.1524–475X.2004.04006.x University of Washington. (2012). School of Nursing University of Washington academics. Retrieved from http://nursing.uw.edu/admissions Vincent, D., Johnson, C., Velasquex, D., & Rigney, T. (2010). DNP-prepared nurses as practitioner-researchers: Closing the gap between research and practice. American Journal for Nurse Practitioners, 14(11/12), 28–34. Woolf, S. (2008). The meaning of translational research and why it matters. Journal of the American Medical Association, 299(2), 211–213. doi:10.1001/jama.2007.26 Zlowodzki, M., Poolman, R. W., Kerkhoff, G. M., Tornetta, P., & Bhandari, M. (2007). How to interpret a meta-analysis and judge its value as a guide for clinical practice. Acta Orthopaedica, 78(5), 598–609.
Preparing practice scholars: Teaching knowledge application in the Doctor of Nursing Practice Curriculum Susan Weber Buchholz, PhD, ANP-BC (Associate Professor)1 , Geraldine M. Budd, PhD, FNP-BC, FAANP (Associate Professor)2 , Maureen R. Courtney, PhD, FNP-BC (Associate Professor)3 , Mary B. Neiheisel, EdD, CNS-BC, FNP-BC, FAANP (Professor)4 , Margaret Hammersla, MS, CRNP (Assistant Professor)5 , & Elizabeth D. Carlson, PhD, MPH, APRN-BC (Assistant Professor)6 1
College of Nursing, Rush University Medical Center, Chicago, Illinois School of Nursing, Widener University, Chester, Pennsylvania 3 College of Nursing, The University of Texas Arlington, Arlington, Texas 4 College of Nursing and Allied Health Professions, The University of Louisiana at Lafayette, Lafayette, Louisiana 5 School of Nursing, University of Maryland, Baltimore, Maryland 6 Mennonite College of Nursing, Illinois State University, Normal, Illinois 2
Keywords Education; program development; research; statistics. Correspondence Susan Buchholz, PhD, ANP-BC, College of Nursing, Rush University Medical Center, 600 S. Paulina Street, Chicago, IL 60612. Tel: 312-563-3590; Fax: 312-942-3038; E-mail: [email protected] Received: September 2012; accepted: January 2013 doi: 10.1002/2327-6924.12050
Abstract Purpose: The purpose of this article is to explore the scholarship role of the Doctor of Nursing Practice (DNP) and the associated knowledge and skills required for success. Data sources: There are excellent competencies provided by national organizations that present guidelines for design and application of this practice scholar’s contributions. Although evidence-based research translation is known to be essential for the DNP scholar, a consensus does not exist about the required research knowledge and skill levels that are needed. Conclusions: A model was developed to depict the scholarship roles of the DNP and the Doctor of Philosophy (PhD). This model indicates both DNP and PhD scholars are alike in their enactment of active scholarship but have different areas of expertise. They are different in their major roles that lead to the development of practice science; the DNP is the expert in knowledge application while the PhD is the expert in knowledge generation. Implications for practice: A nurse practice scholar needs to have a fundamental and strong understanding of research design and interpretation in order to appraise and implement research-based evidence into practice and conduct clinical projects.
Practice scholars: DNP knowledge, skills, and roles for scholarship The nursing profession urgently needs professionals with knowledge to support the delivery of safe, cost efficient, evidence-based quality health care. It is fortuitous that a new nursing role, the Doctor of Nursing Practice (DNP), has appeared at this time of great healthcare need (Sperhac & Clinton, 2008). The knowledge base required by DNP-prepared nurses is such that DNP scholars are able to provide expert consultation and judgment on practice issues to support the best possible patient care (American Association of Colleges of Nursing, 2006b). It is necessary that DNP students become experts in using
the widest possible array of resources in their efforts to translate and build evidence-based health care. DNP graduates are prepared to become leaders in the clinical realm. Few deny the need for additional nursing expertise to increase the quality of health care. However, the scholarship dimension of the DNP role has resulted in many questions as to its scope, rigor, fundamental nature, and purpose. Faculty with the PhD degree and others seek clarification of the DNP role in scholarship and research. Although evidence-based research translation is known to be essential for the DNP scholar, a consensus does not exist about the required research knowledge and skills that are needed for achievement. The purpose of this article is to explore the nature of DNP scholarship
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needed for practice. The specific aims are to discuss the history of research and the DNP role; present a model that depicts the scope of DNP scholarship and compare this to the well-known PhD role; describe the specific and necessary DNP skills for achieving research competencies; and recognize that, together, DNP and PhD colleagues can create seamless systems of evidence-based care to achieve desired patient outcomes.
DNP competencies for clinical scholarship Included in pressing healthcare concerns of this century is an aging and more diverse population than ever before seen, an information explosion that entails rapidly changing technology, and a demand for excellent and increasingly complex health care. These continual intellectual, technological, and physical advancements and changes in our society necessitate updates and progress in the education of all healthcare providers. Nurses, the largest group of healthcare providers, have long been concerned about the many pressing issues influencing health care (American Nurses Association, 2012). In order to address the many facets of complex health care, nurses at the baccalaureate level are provided with a basic understanding of the research process and how to use reliable evidence to inform their practice (American Association of Colleges of Nursing, 2008). This basic empirical knowledge provides a foundation for nurses who pursue masters’ degrees and are taught not only how to continue to use current evidence in practice but also to identify healthcare knowledge gaps. Master’s prepared nurses apply outcomes derived from research to resolve problems encountered in practice and disseminate those results in order to advance clinical practice (American Association of Colleges of Nursing, 2011). However, the critical and collective healthcare issues facing the nation have resulted in a call for more nurses with advanced educational preparation beyond the master’s degree level. The American Association of Colleges of Nursing voted to endorse programs granting a DNP degree with the goal of improving the systems affecting individual healthcare delivery (American Association of Colleges of Nursing, 2004). Echoing the American Association of Colleges of Nursing, the National Academy of Science stated “The need for doctorally prepared practitioners and clinical faculty would be met if nursing could develop a new non-research clinical doctorate, similar to the M.D. and Pharm. D. in medicine and pharmacy, respectively” (National Research Council of the National Academies, 2005, p. 74). In the ensuing years, several nursing organizations, including the American Association of Colleges of Nursing, American Nurses Association, and National Or474
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ganization of Nurse Practitioner Faculties developed and published both the conceptualizations of the nursing doctorate degree and the competencies needed for practice at this advanced level (American Association of Colleges of Nursing, 2012b; American Nurses Association, 2011; National Organization of Nurse Practitioner Faculties, 2006). The ability to critically analyze data that are used to translate evidence-based knowledge into practice settings is important to each of these organizations. Universities throughout the United States have developed curricula using the competencies detailed by nursing’s various governing bodies. The number of DNP programs is increasing rapidly. In 2006, there were only 20 DNP programs and there are now over 180 DNP programs in the United States (American Association of Colleges of Nursing, 2012a, 2012b). Providing specific and detailed information about how to operationalize the research competencies necessary for DNP curriculum is important.
A model for practice and research scholarship DNP programs are preparing graduates to be able to practice at the highest level in multiple clinical settings, leading the way in the application and translation of disseminating successful research findings into practice. PhD programs are preparing graduates to become leaders in conducting scientific research, to advance empirical knowledge that can be utilized to improve health outcomes for people across the life span (Rush University, 2012; The John Hopkins University School of Nursing, 2012; The University of Iowa, 2012; University of Washington, 2012). A model was developed to depict the scholarship activities of the DNP and the PhD graduates (Figure 1), which indicates both DNP and PhD scholars are alike in their enactment of active scholarship but have different areas of expertise. They are different in the major activities undertaken that lead to the development of practice science. The DNP curriculum approach focuses on expertise in knowledge application, while the PhD curriculum approach centers on expertise in knowledge generation. In general, the DNP scholar’s expertise is in the areas of evidence appraisal and research synthesis, using rigorously developed skills. The DNP scholar is accountable as a clinical leader to translate research to unique clinical settings and populations, including implementing interventions, evaluating outcomes, and integrating best practices that have been verified by research and thus making contributions to the cycle of evidence-based practice (American Association of Colleges of Nursing, 2004). In a complementary fashion, the PhD graduate’s expertise as a scholar is through independent, original research conducted to describe, explain, predict, and, ultimately
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Research Scholar
Practice Scholar
Both are full scholars, emphasis is different
Knowledge Application
Appraisal Research Synthesis Translation Implementation Evaluation Integration
Knowledge Generation
EBP Enrichment Cycle
Independent Research of Phenomena: Description Explanation Prediction Control
PhD
DNP
Courtney, 2011 Figure 1 A model for practice and research scholarship.
control phenomena of concern to nursing. Expert knowledge generation is the PhD specialist’s contribution to the cycle of evidence-based practice (American Association of Colleges of Nursing, 2006a). The scholarship dimension of either doctoral role is incomplete without the other. Knowledge generation alone is insufficient in a practice discipline; without careful translation it will not serve patients. Likewise, one cannot apply knowledge to practice that does not have sufficient validity and reliability produced through the efforts of nursing’s research scholars. Only in collaboration, can the DNP and PhD scholars create and weave the body of clinical knowledge required to achieve desired patient outcomes. It is important to note that the authors and others (Vincent, Johnson, Velasquex, & Rigney, 2010) acknowledge that occasional overlap in these areas of expertise and activity will occur between the two roles. The DNP-prepared nurse uses skills of evidence appraisal and research synthesis as identified in the model. These are the most well-known skills associated with the role and fundamental to the DNP scholar’s contribution to clinical practice. The specific aspects of these areas will be discussed in a later section. The DNP graduate provides leadership to translation of knowledge to the clinical setting. The DNP-prepared nurse must analyze the appropriateness of specific knowledge to be translated to a specific setting. This entails consideration of the patient population, staffing, administrative resources, openness to change, and other unique factors in a given setting. If evidence is judged ready for
translation to the setting, a detailed implementation plan must be developed. After that interventions that have been implemented for a specific patient population and setting must be carefully evaluated to determine applicability to the chosen clinical environment. Evaluation questions that the DNP scholar must pursue include the degree of commitment and fidelity with which staff implement an intervention and specific patient outcomes for those receiving the intervention in the designated setting (Courtney & Neiheisel, 2011). This evaluation of the validity of research evidence used in the DNP-prepared nurse’s setting is required to determine the effectiveness of the knowledge translation. When interventions have been positively evaluated in the DNP-prepared nurse’s setting, leadership by the DNP is required to successfully integrate care approaches into the system. The DNP scholar can assist to maintain a continuously evolving care setting that integrates the most effective and efficient clinical practice. These are the DNP scholar’s activities that contribute to the cycle of evidence-based practice. The PhD-prepared nurse’s expertise as a scholar is through independent, original research to create, replicate, and/or extend knowledge. This requires expertise in knowledge of relevant theory, research methodologies, and statistical analysis. In addition, topics for knowledge generation for the PhD student and graduate should be formed by high-value clinical practice questions, often identified by the DNP. The model (Figure 1) depicts the strengths and skills of both scholar roles and shows that it is through a balance of their respective areas of expertise that the evidencebased enrichment cycle is achieved. Nursing and patients benefit from the collaborative scholarship contributions of both roles (Edwardson, 2010).
Organizing a knowledge application framework for the practice scholar The development and application of research and evidence will take a different focus for the DNP-prepared nurse when compared to the PhD-prepared nurse. A set of essential skills is needed for all doctorally prepared nurses who engage in clinical scholarship. For DNP students, the goal is knowledge application, which requires mastery of a significant body of research intended to support this function. The foundational knowledge needed to provide the highest standard of patient care includes appraisal, research synthesis, translation, implementation, evaluation, and integration. Inherent in these steps is an expertise in understanding and interpreting research findings so that the skills can be used to understand the existing evidence and to design and implement 475
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processes to evaluate related outcomes. A thorough understanding of this knowledge will enable DNP students to enhance quality improvement and to participate in practice-related research as needed (American Association of Colleges of Nursing, 2006b).
Skills for appraisal of the evidence Developing a precisely formulated clinical question is the foundation for completing a thorough literature search of available evidence. This is an integral research competency for all doctoral students. DNP students must demonstrate the necessary skills to consistently and thoroughly evaluate evidence on a given topic so as to make positive practice changes and promote the highest level of care. Each integral step in the literature review process needs to be achieved. A successful literature examination begins with a calculated search strategy. Knowing which key words to use, how to use the combinations of key words that are most accurate and will produce the greatest yield, how to use Boolean operators, and how to use a multitude of databases will allow students to very efficiently search the literature (Levy & Ellis, 2006). This skill set may be used for an integrated literature review or a systematic review, but just as likely it may be used to find key articles to implement patient or system change in healthcare settings. An integral point in the successful literature search is using available resources. Helping DNP students establish early working relationships with information specialists in the university or hospital provides DNP students with strong search allies (Scherrer & Dorsch, 1999). When the literature is appraised, DNP students must learn to quickly decipher several components. First, literature must be deemed to be not only accurate, but from a high-quality source and an original citation. Second, research studies must be judged to be relevant to what is needed and also be found important to the broader stakeholders involved. Third, literature must be applicable to the clinical question (Fineout-Overholt, Melnyk, Stillwell, & Williamson, 2010). The following sections outline critical research knowledge and skill development for the DNP student. These include development of a high-level literature review and analysis, development of evidence-based practice and clinical outcomes, and research methodology and procedure proficiency.
Systematic reviews and expert content Systematic reviews are one form of secondary research that students will examine and produce. DNP students should be able to determine overall factors that make for a strong systematic review and be able to evaluate 476
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specifics of each research study included in a systematic review. DNP students must examine each of the studies included in systematic reviews of quantitative research for validity. They must be conversant with the Cochrane Collaboration and specific Cochrane Reviews, and must understand the Cochrane’s guidelines for reviewing and reporting results of randomized controlled trials, systematic reviews, and meta-analyses. Carefully reviewing how each of the authors came to conclusions, and the specific processes used, is critical to appraising the overall rigor of any systematic review and is best guided by sources, such as the Cochrane Handbook (Higgins & Green, 2011). Engaging in the process of conducting a systematic review allows the student to better learn its process and components. While graduates should never conduct this type of review without a team, it can be a quite useful learning experience for students and results in their developing skill in searches and evidence appraisal. Many students use the understanding they have gained from conducting their own systematic review as the basis for designing their scholarship projects. The review of specific research reports should follow the standards identified by the Cochrane Collaboration. For randomized controlled trials the Consolidated Standards for Reporting Trials (CONSORT; Hopewell et al., 2008; Schulz, Altman, & Moher, 2010) is the accepted guide. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) provides procedures on reporting and reviewing systematic reviews and meta-analyses (Moher, Liberati, Tetzlaff, Altman, & The PRISMA GROUP, 2009). Consistent and skillful use of the available resources will aid students in understanding research findings and in further establishing evidence-based use implications of systematic reviews. The most demanding standard of systematic review is the statistically performed meta-analysis of multiple research studies. The results of a meta-analysis are presented by the type of data used to formulate the results. This level of analysis is often prohibited because of studies using different variables and statistical procedures. Therefore, a critical skill for assessing systematic reviews is the analysis for heterogeneity of the data and assessing which strategies are employed to manage a dilemma with lack of heterogeneity. Differentiation between use of dichotomous data or continuous data is a useful skill. Interpretation of effect size, forest plots, confidence intervals, and p values will aid in deciding if the systematic review is worthwhile to use in changing clinical practice (Thomas, Ciliska, Dobbins, & Micucci, 2004; Zlowodzki, Poolman, Kerkhoff, Tornetta, & Bhandari, 2007). The utilization of qualitative data is becoming increasingly more prominent in understanding how to realistically implement practice-based evidence in the clinical
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and community setting (Leeman & Sandelowski, 2012). Utilization of qualitative metasummary as well as qualitative metasynthesis are useful for the interpretation of qualitative systematic reviews (Cohen & Crabtree, 2008) Qualitative metasummary provides a method to aggregate qualitative findings, and can be used when mixed research syntheses are needed to answer important clinical questions (Sandelowski, Barroso, & Voils, 2007). Metasynthesis is particularly useful when trying to determine the feasibility, appropriateness, and meaningfulness of a health-related question (Joanna Briggs Institute, 2012). In all systematic reviews, it is imperative to assess the question and the methodology chosen to answer the question and to ask how the data were extracted, coded, pooled into categories, and ultimately synthesized.
Evidence-based practice and clinical outcomes For evidence-based practice, there are many national and international resources that can be used by DNP students. Appraisal tools that are useful for DNP students exist beyond appraising systematic reviews and randomized control trials. The Critical Appraisal Skills Program (CASP) tools provide a way to critically appraise qualitative research, economic evaluation studies, cohort studies, case–control studies, and diagnostic test studies (Critical Appraisal Skills Programme, 2011). Narrative and thematic content also can be examined systematically (Mays, Pope, & Popay, 2005). The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument is a frequently used tool for evaluating consensus guidelines (The AGREE Collaboration, 2001). The six quality domains in the AGREE instrument are “i) scope and purpose; ii) stakeholder involvement; iii) rigour of development; iv) clarity of presentation; v) applicability; and vi) editorial independence” (AGREE Enterprise, 2010). DNP students need to be able to quickly interpret the level of evidence, which is the hierarchy of study evidence. Typically, systematic reviews are at the highest level. When evaluating research, it is important to ask the question ”what is the level of the research” (Oxford Centre for Evidence-based Medicine, 2009). DNP students must be instructed to ask about the strength of recommendations and if the evidence is strong enough to recommend using an intervention (Ebell et al., 2004). By understanding level of evidence and strengths of recommendations, DNP graduates can provide sound advice for implementing changes. Evidence-based practice is informed by the best available evidence, clinical expertise, patient values and preferences, and available resources (Melnyk & Fineout-Overholt, 2010). Being able to integrate these typically uneven aspects of evidence-based
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practice requires integrating statistical knowledge, systematic review, expert content, and clinical experience.
Research methodology proficiency Evaluating and translating research requires proficiency of understanding research to accurately interpret other study analyses or research synthesis. In addition, it may be that DNP students will undertake a project that is research-based and thus, need to plan a study themselves. DNP curriculum developers may take multiple approaches in providing guidelines that facilitate choosing an appropriate research questions. One approach that Cochrane takes to asking an answerable question is the “PICOT” question (Cochrane Public Health Group, 2012). The “PICOT” question is a time-tested method of unraveling a research question down to the components that it is representing. “P” represents the patient population of interest. “I” represents the intervention or area of interest in the study. “C” represents the comparison or control to the intervention. “O” represents the outcome of the study and “T” represents the time frame of the study. The PICOT question provides a framework that can be easily used when retrieving the literature (Facchiano & Snyder, 2012; Richardson, Wilson, Nishikawa, & Hayward, 1995; Thabane, Thomas, Ye, & Paul, 2009). Variable identification and level of measurement identification are essential components of research. Assuring that DNP students can correctly identify the variables is critical; the independent variable, the variable of manipulation, and a dependent variable must all be identifiable. In the case where a research study does not have an independent variable and a dependent variable, then helping students identify the phenomenon of interest is important (Polit & Beck, 2008). Identifying if the study uses nominal or discrete data, ordinal or rank-ordered data, interval or continuous order data, or a combination of these measures is likewise important. When DNP students develop their own projects, they should use the highest order of data as possible so as to produce the most thorough results (Polit & Beck, 2008). Guiding DNP students to understand psychometric properties, particularly in relation to tools or instruments, is essential for several reasons. Choosing instruments that correctly and consistently measure an identified concept is critical for assuring study validity (Polit & Beck, 2008). Using reliable instruments and being able to determine if stability, internal consistency, and/or equivalence is being assessed is important not only for an individual project, but also for evaluating if completed research is replicable and translatable. Being able to understand, if statistical conclusion validity, the multiply construed construct validity, internal validity, or external validity is being assessed, is 477
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important in understanding if an instrument has been designed correctly. Assessment of instrument feasibility, including type of measures, length, cost, language, literacy, and ease of use will help to determine its appropriateness for use. Standard research texts emphasize these properties so that the participant does not become overburdened (Polit & Beck, 2008). While in the social sciences, reliability and validity have been used as concepts for examining terms used to define the rigor of qualitative research, evaluating trustworthiness of a qualitative study is important to determining worth. Establishing if qualitative research has trustworthiness involves understanding study credibility, transferability, dependability, and confirmability (Lincoln & Guba, 1985). Strong qualitative research is ethical, important, clear, and credible. In addition it can be verified; uses appropriate arduous methods; assesses for reflexivity; and provides guidance in utilizing strong qualitative research to guide clinical decision making (Cohen & Crabtree, 2008).
Research procedure proficiency DNP projects can use a quantitative nonrandomized preexperimental (pre–post) design. However, when the research question is appropriate, advisors can guide DNP students to consider a quasi-experimental or randomized control experimental design. This will require a little more effort but the answers to clinical questions will have greater validity. It is recognized that not all DNP projects will involve evaluation of an intervention. With qualitative DNP work, the DNP students need two key factors in place. The first is a methodology that is appropriate for the question; the second is a faculty member experienced with that type of methodology, whether it is focus groups, grounded theory, phenomenology, ethnography or other qualitative methodology (Polit & Beck, 2008). For both quantitative and qualitative research projects, students will need both access and faculty to help them with the use of scientific data analysis software. Being grounded in descriptive statistics is useful, so doctorally prepared nurses have a fundamental level of knowledge as they translate scientific findings into the practice setting (American Association of Colleges of Nursing, 2006a). The level of inferential statistical knowledge that is needed is dependent on the design needed to answer the clinical question(s) encountered in the future. This is arguably one of the areas of greatest difference between DNP students and PhD students. A high-level understanding of complex inferential statistics is likely not necessary for DNP students. Without a fundamental understanding of inferential statistics, DNP students will struggle to understand how to analyze and interpret their 478
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findings and, equally important, the findings of other authors that they will read and review to guide their practice when they are graduates. DNP scholars make critical contributions to providing the highest quality patient care possible. To assist them to do this, multiple tools and resources are available. For example, Standards for Quality Improvement Reporting Excellence (SQUIRE) is an effective tool for evaluation of quality improvement projects (SQUIRE, 2008). The expected outcome of exposure to this research information is to allow DNP students to work with the clinical situation and setting at hand along with the patients and caregivers who are already in place, so as to provide the best evidence-based practice client-centered care possible.
Moving the research forward as a DNP Translational research is taking an ever-increasing place in today’s healthcare research landscape. This is demonstrated by the National Institutes of Health’s Clinical and Translational Science Award program that was launched in 2006. Currently there are two basic forms of translational research. The first being the idea of “bench-tobedside” research that is the purposeful practice of ensuring that new treatments and knowledge benefit the population for which they were intended (T1). The second aims to reduce the gap between knowledge and practice while obtaining improved quality of care (T2; Woolf, 2008). The Institute of Medicine’s Clinical Research Roundtable further differentiates these two forms of translational research. T1 involves understanding how disease mechanisms that have been described at the bench can provide new methods for diagnosis, therapy, and prevention. T2 seeks to move these new methods beyond clinical trials/studies and into everyday clinical practice (Sung et al., 2003). Implementation science is a specific form of T2 research. Implementation science directly impacts the ability to improve both quality and effectiveness of healthcare delivery services by using rigorous scientific methods that include clinical research findings and additional evidence-based practice knowledge (Eccles, 2006). Implementation science, while clearly important for moving effective programs into everyday practice, continues to face challenges, and is an area ripe for DNP and PhD scholars to provide significant impact at the ground level of healthcare changes in multiple settings (Irwin & Supplee, 2012), It is clear that DNP students are poised to lead the movement of translational and implementation research. DNP students will need to have a strong foundation of research design and statistical analysis as described earlier. Although outside the scope of this article, an understanding of organizational theory and health policy, coupled
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with a strong research base, is necessary. Having knowledge in these additional areas will help to facilitate the development of expert clinicians with the expertise to evaluate not only the literature, but how to realistically implement and manage practice change on an organizational scale.
Conclusion Debate about how much and what type of research knowledge is needed for DNP students has resulted in considerable discussion for curriculum committees in many schools and colleges of nursing. There are excellent competencies provided by national organizations that present guidelines for design and application of this practice scholar knowledge. However, the general research knowledge base for DNP students depends in part on how much of a research and statistical base is envisioned by a curriculum committee, as being needed for the DNP scholar to fully appraise the evidence and realistically implement evidence-based programs and solutions to ongoing challenges and difficult problems in the healthcare realm. This article makes the argument that a nurse practice scholar needs to have a fundamental and strong understanding of quantitative and qualitative research design and interpretation to implement researchbased projects into practice. Given the egalitarian natures of the DNP and PhD roles, it is important to keep in mind from a curricular perspective, the knowledge that is needed to maximize what the DNP-prepared nurse and the PhD-prepared nurse each require as they work together to provide optimal health care. If scholarly biases exist between DNP and PhD scholars, then these biases need to be set aside in order to provide panoramic opportunities to improve health outcomes. Individuals and populations across the life span stand the most to gain when DNP and PhD scholars work together with mutual respect as they address the critical healthcare needs of our nation.
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