reconceptualizing the core of nurse practitioner education and practice

EDUCATION

Reconceptualizing the core of nurse practitioner education andpracticeMaryE. Burman,PhD, APRN, BC (Professor), AnnMarieHart,PhD,APRN, BC (Assistant Professor), VirginiaConley,PhD, APRN, BC (Assistant Professor), Julie Brown, ND, FNP-C (Assistant Lecturer), Pat Sherard, MS, APRN, BC

(Adjunct Faculty), & Pamela N. Clarke, PhD, RN, FAAN (Professor)

Fay W. Whitney School of Nursing, University of Wyoming, Laramie, Wyoming

Keywords

Doctor of nursing practice; advanced practice

nursing; nurse practitioners.

Correspondence

Mary E. Burman, PhD, APRN, BC, Fay W.

Whitney School of Nursing, University of

Wyoming, Dept 3065, 1000 E. University

Avenue, Laramie, WY 82071.

Tel: 307-766-8291; Fax: 307-766-4294;

E-mail: [email protected]

Received: March 2007;

accepted: February 2008

doi:10.1111/j.1745-7599.2008.00365.x

Abstract

Purpose: The movement to the doctor of nursing practice (DNP) is progressing

rapidly with new programs emerging and curricular documents being devel-

oped. We argue that the implementation of the DNP is a good move for nursing,

provided that we use the opportunity to reconceptualize the core of advanced

practice nursing, especially nurse practitioner (NP) practice.

Data sources: Theory and research articles from nursing focused on advanced

practice nursing, NPs, and doctoral education.

Conclusions: The foundation of NP education is currently based essentially on

borrowed or shared content in assessment, pharmacology, and pathophysiol-

ogy. We argue that the heart and soul of nursing is in health promotion, both in

healthy persons and in those dealing with chronic illness. Current master’s

programs do not prepare NPs to assume high-level practice focused on health

promotion and disease management using the latest theoretical developments in

health behavior change, behavioral sciences, exercise physiology, nutrition, and

medical anthropology. Although these are touched upon in most NP programs,

they do not represent the core science of NP education and need to be a critical

part of any DNP program.

Implications for practice: Ultimately, our vision is for NP care to be consis-

tently ‘‘different,’’ yet just as essential as physician care, leading to positive

outcomes in health promotion and disease management.

There is growing consensus that there are significant

problems with the quality of health care in the United

States (Institute of Medicine [IOM], 1999, 2001, 2003).

The American Association of Colleges of Nursing (AACN,

2004) responded to these concerns in a position statement

focusing on the role of nursing, particularly advanced

practice nursing, in addressing some of the current health-

care problems. A key strategy outlined in this report is the

development and implementation of the nursing practice

doctorate to prepare advanced practice nurses (APNs) who

can fill the growing societal need for expert clinicians to

assume major leadership roles in clinical, management,

and evaluation and outcomes research arenas. Doctor of

nursing practice (DNP) programs include extensive clinical

practical and a have a strong focus on scholarly and

evidence-based practice. Moreover, the DNP would offer

APNs a degree commensurate with their preparation

because most APN master’s programs are overcredited

with some requiring more than 60 credit hours. Thus,

in spring 2005, AACN members voted to move the current

level of preparation necessary for advanced practice nurs-

ing from the master’s degree to the doctorate level by the

year 2015.

We argue that the move to the DNP is beneficial and

justifiable, providing that we use this opportunity to rec-

onceptualize the core of advanced nursing practice. While

Journal of the American Academy of Nurse Practitioners 21 (2009) 11–17 ª 2009 The Author(s)Journal compilation ª 2009 American Academy of Nurse Practitioners

11

some programs have used the DNP to transform their APN

programs (e.g., Draye, Acker, & Zimmer, 2006), many DNP

programs do not reflect a new vision of what is founda-

tional to advanced nursing practice. Rather, they primarily

provide an additive model, whereby the new degree sim-

ply builds upon existing master’s programs content by

adding or expanding content on leadership, practice man-

agement, and information technology. Current master’s

programs, particularly nurse practitioner (NP) programs,

are based on assessment, pathophysiology, and pharma-

cology and prepare NPs to provide care that is strikingly

similar to physicians. While content from these areas is

critical to NP practice, we maintain that nursing content

(i.e., health promotion and disease prevention) should be

the foundation of NP education and view the move to the

DNP as an opportunity to reconceptualize the core of NP

practice and education. Focusing on the core of NP practice

is also timely, given the national discussion to develop

a consensus model on APRN regulation, practice, and

education (Johnson, 2007).

In this article, we review current master’s level NP

education as well as the literature related to master’s level

NP education and practice and explain how each of these

points to the need for a reconceptualization of APN prac-

tice. We then discuss our reconception of the core of NP

practice and education as we move to the DNP for

advanced practice nursing.

Current NP practice and education

APNs have a long history of providing accessible, cost-

effective, high-quality health care to people from all walks

of life (Hamric, Spross, & Hanson, 1996). Specifically, NPs

have made incredible strides since the development of the

first educational programs. At present, approximately

94% of all NPs are nationally certified (Goolsby, 2005),

and across the United States, NPs can obtain prescriptive

authority and are eligible to receive reimbursement for

their services by Medicaid, Medicare, and most health

maintenance organizations and other forms of third-party

reimbursement (Towers, 2005). Consequently, NPs are

playing a more substantial role in health care, with evi-

dence that they are providing an increasingly higher

percentage of health care to the U.S. population. In

1997, it was estimated that more than 16% of the U.S.

population had had at least one visit with an APN (Druss,

Marcus, Olfson, Tanielian, & Pincus, 2003). An analysis of

adult outpatient visits between 1995 and 2001 indicated

an 11% increase in physician visits versus a 77% increase

in nonphysician (including NPs and physician assistants)

visits (Roumie et al., 2005). More importantly, results from

numerous studies indicate that NP-directed care results in

outcomes similar to physician-directed care but with

higher reports of client satisfaction (Kinnersley et al., 2000;

Mundinger, Kane, et al., 2000; Shum et al., 2000).

Furthermore, after several decades of an often tenuous

relationship with NPs, many physicians are now recog-

nizing the excellent primary care services provided by NPs

and are considering these as they make predictions for

their own future workforce needs (Phillips, Dodoo, Jaen, &

Green, 2005; Reeves, Hermens, Braspenning, Grol, &

Sibbald, 2005; U.S. Department of Health and Human

Services, 2005).

NP practice

Despite the tremendous strides made by NPs, signifi-

cant shortcomings exist in relation to NP practice and

education. With regard to practice, throughout the his-

tory of advanced practice nursing, NPs have been criti-

cized for practicing too similarly to medicine (Campbell,

1998; Rogers, 1975; Weintraub, 1998; Weston, 1975). NP

supporters have countered this claim by maintaining that

nursing encompasses all aspects of health care, including

but not limited to the diagnosis and treatment of disease,

and by emphasizing that NPs provide services in a holistic,

client-centered (i.e., nursing) fashion (Ford, 1997;

Mauksch, 1975). However, in many respects, NP critics

are not incorrect; NPs do tend to practice in a manner

quite similar to physicians. For example, at present, the

main practice setting for NPs are physicians’ offices

(Goolsby, 2005). In addition, NPs and physicians tend

to use the same general approach to patient care: The

patient checks in at the front desk and after waiting for

a period of time is escorted to a small examination room,

where his or her vital signs are obtained by an office nurse

or other associate. The patient is then left alone to wait for

the physician or NP clinician. After performing a history

and physical examination, the clinician then discusses

the findings with the client, who usually leaves the

clinician’s office with an oral plan of care and a written

prescription. While there is nothing inherently wrong

with NPs using the same general approach as physicians,

this approach represents an important aspect of health-

care delivery that has been adopted by many NPs without

challenge or critical reflection.

NPs and physicians also use the same diagnostic and

billing codes and document their services in an almost

identical problem-focused (i.e., SOAP note) fashion

(Buppert, 2003). While nursing possesses its own diagnostic

classification system (North American Nursing Diagnoses

Association, 2004) as well as its own set of interventions and

outcomes (Johnson, Bulechek, Dochterman, Maas, &

Moorhead, 2001), only a minority of APNs actually use

nursing diagnoses (Martin, 1995). Furthermore, the few

APNs who do use them can only be reimbursed for services

Reconceptualizing NP education and practice M.E. Burman et al.

12

that are accompanied by an approved medical diagnosis

(i.e., International Classification of Diseases [ICD], ninth

revision code) and a recognized Current Procedural Tech-

nology (CPT) code (Buppert).

Following the premise that NPs practice in a manner

auspiciously akin to physicians is the fact that most of the

research studies examining NP quality and performance

have compared NP to physician outcomes (Kinnersley

et al., 2000; Mundinger, Kane, et al., 2000; Shum et al.,

2000). While the results of these studies indicate that NP-

directed care is associated with outcomes similar to phy-

sician-directed care, the outcomes examined in these

studies have been general to all the allied health disciplines

(e.g., physiological status, cost of care, and utilization of

services) and have not reflected the added value of nurs-

ing. For example, in their study of nurse-sensitive out-

comes, Ingersoll, McIntosh, and Williams (2000) found

that the 10 highest ranked outcomes identified by APNs

included ‘‘satisfaction with care delivery, symptom reso-

lution/reduction, perception of being well cared for, com-

pliance/adherence with treatment plan, knowledge of

clients and families, trust of care provider, collaboration

among care providers, frequency and type of procedures

ordered and quality of life’’ (p. 1272). Unfortunately, only

a few of these items have been included in the outcomes

studies to date. Clearly, to describe and justify the unique

value of NP care, we need to be measuring nurse-sensitive

outcomes. The process and outcomes associated with NP

care can and should be representative of the best that

nursing has to offer.

Adding to the complexity of practice issues is the grow-

ing specialization in advanced practice nursing. A variety

of specialized APN roles have recently emerged, including

a number of new NP roles, such as holistic NP and der-

matology NP. Consequently, it is less and less clear what

constitutes the core of NP practice. This lack of clarity about

the core of NP practice is highlighted in a survey of

oncology APNs, which suggests that a lack of core com-

petencies for this specialization may be creating problems

(Lynch, Cope, & Murphy-Ende, 2001). APNs in this study

reported barriers related to the lack of a specialty APN

definition, reimbursement issues, variance in education,

merging of current roles, and certification. Thus, nursing

must ask itself what ties all these different types of NPs

together? What is the core and foundation of NP practice?

How does it build upon basic nursing preparation?

NP education

Similar to practice, NP education has also undergone

much transformation. In 1973, there were only 65 NP

programs in the United States and most of these offered

postgraduate certificates. As of 2001, there were 327 NP

programs and almost all these were at the master’s level

(Pulcini & Wagner, 2002). In addition, all NP educational

programs are expected to meet or exceed the guidelines

outlined in the criteria developed by the National Task

Force on Quality Nurse Practitioner Education (2008) as

well as the specialty competencies developed by the

National Organization of Nurse Practitioner Faculties

(U.S. Department of Health and Human Services, 2002).

Despite these educational strides, NP curricula guide-

lines are also not so dissimilar from medicine. At present,

the core of advanced practice nursing is assessment, path-

ophysiology, and pharmacology; however, these content

areas are fundamental to all the allied health disciplines

and do not differ significantly from one discipline to the

other. While master’s level NP programs contain content

related to nursing theory and research, with regard to

actual NP therapeutics, the content is primarily based in

pharmacology. Aside from their educational backgrounds,

many NPs admit to having a close allegiance to the medical

model. For example, in a study by Blasdell, Klunick, and

Purseglove (2002), NPs indicated that a ‘‘wellness/health

promotion’’ model was most important for their practice;

however, they rated the medical model as the next most

important above several nursing models. In their review of

NP theory, Nicoteri and Andrews (2003) come to a similar

conclusion, ‘‘The NP role evolved from nursing yet is

heavily influenced by medicine’’ (p. 494).

In addition to having a core curriculum that is strikingly

similar to medicine, other educational concerns exist,

including the fact that many NPs view their educational

experiences as less than adequate. In a national survey of

592 NPs, Hart and Macnee (2007) discovered that many

NPs felt that their formal education had inadequately

prepared them for practice. When asked, ‘‘how prepared

were you for actual practice as an NP immediately after

completing your basic NP education,’’ less than 10% of the

NPs indicated that they were ‘‘very well prepared.’’ While

38.5% indicated being ‘‘generally well prepared,’’ the

same percentage indicated that they were only ‘‘somewhat

prepared,’’ 11% indicated that they were ‘‘minimally pre-

pared,’’ and 2% indicated feeling ‘‘very unprepared.’’ The

NPs also indicated that they felt most prepared in the areas

of differential diagnosis, pharmacology, health assess-

ment, health teaching, and the management of acute

and chronic illnesses and least prepared for clinical skills,

electrocardiogram and radiology interpretation, coding

and billing, the use of alternative therapies, and the man-

agement of mental health diseases. In addition, the study

participants indicated that NP education needed more

rigor and clinical hours and that NPs should be taught

by more experienced clinicians.

Similarly, in a national study of NP educational pro-

grams, program directors indicated that they were most

M.E. Burman et al. Reconceptualizing NP education and practice

13

dissatisfied with their programs’ coverage of business

management and electronic information systems. In

addition, the directors identified ‘‘an already crowded

curriculum’’ and ‘‘limited availability of clinical learning

sites’’ as the most significant barriers to curriculum

change (Bellack, Graber, O’Neil, Musham, & Lancaster,

1999). Finally, gaps in clinical decision making and use of

available evidence exist. For example, Cogdill (2003)

found that NPs seek clinical information from colleagues,

drug reference books, textbooks, and protocol manuals

much more frequently than they do from journal arti-

cles. Additionally, in their work on NP clinical decision

making, Burman, Stepans, Jansa, and Steiner (2002)

identified that NPs use a variety of clinical resources in

their diagnostic reasoning and client care planning,

including several elements commonly associated with

evidence-based practice (e.g., client values and clinical

experience); however, their results did not indicate that

the NPs were attempting to access or use best research

evidence.

Over the past century, advanced practice nursing has

witnessed incredible advances and has earned its place as

a well-respected, highly used, effective form of nursing

care. Despite this growth, NP practice, education, and

research continue to be rooted in many of the traditions

established by medicine. Current debates and discussions

regarding the proposed DNP as well as the projected

changes in the nation’s healthcare needs (IOM, 2001)

provide NPs with the incredible opportunity to recon-

ceptualize advanced nursing practice into an ideal form

of health care. In the words of Mundinger, Cook, et al.

(2000): ‘‘If the nursing science is not incorporated into

generic primary care training, advanced practice nursing

programs will produce only weak imitations of physician-

based medical care, not capitalizing on and profiling the

difference—the added value of nursing’’ (p. 325).

Reconceptualization of the NP core

Change is often one of the most creative times for

innovation. As nursing moves toward the DNP, we have

the opportunity and responsibility to reconceptualize

what advanced practice nursing could and should be.

Reconceptualization of the NP role should start with

a reaffirmation of what has traditionally stood as the heart

and soul of nursing. Disease prevention has always been

seen as the soul of nursing, while health promotion has

been its heart. In nursing, we have espoused health pro-

motion and disease prevention as the foundation of our

practice and as the delineation of what makes nursing

distinct from other professions, especially medicine. In

fact, NP program directors rated health promotion–disease

prevention as one of the highest priorities for NP educa-

tional programs (Bellack et al., 1999). As Alpert, Fjone, and

Candela (2002) so clearly articulate:

Providing medical care is just one aspect of primary

care. Patient education and expert knowledge in

motivation and behavior change will enable NPs to

become the logical providers in primary care, because

so much of health care at this level is about motivating

behavior changes. Their unique knowledge, skills, and

education will enable NPs to be uniquely successful in

assisting health behavior changes. (p. 86)

Therefore, any reconceptualization of NP education and

practice must maintain a strong focus on health promo-

tion and disease prevention. Unfortunately, while paying

much lip service to the criticality of these concepts, current

master’s programs do not prepare NPs with a strong base

for interventions in these two areas. After all the common

disease states, the management of those diseases and the

requisite skill sets of assessment and pharmacology are

taught, little time is left in typical NP curricula to focus on

the theoretical bases for health promotion and disease

prevention. Moreover, the health promotion and disease

prevention that occur within current practice models are

often implemented as disease management. Examples of

this include teaching clients to take medication, do stretch-

ing for back pain, follow special therapeutic diets, do

postcardiac exercises, use nebulizers, or check peak air

flow and blood sugar in persons dealing with chronic

illness. While essential and of importance because they

are reimbursable interventions, they do not constitute the

full range of health promotion options. Real health pro-

motion promotes health; it does not focus on or emphasize

disease. Health promotion in a reconceptualized NP model

is directed toward empowerment and self-care, with

emphasis on promoting positive health behavior change.

It includes NP actions that support lifestyle changes to

prevent disease and promote health, not simply to manage

disease.

While nursing has a strong allegiance to health pro-

motion and prevention and these concepts are touched

upon in most NP programs, unfortunately, they do not

represent what is currently considered ‘‘core’’ content for

advanced practice. At present, the core includes advanced

assessment, pharmacology, and pathophysiology, which is

not significantly different from what is found in traditional

medical education. The consequences of our core reflect-

ing a borrowed set of knowledge is most evident in the

examination of the outcomes of NP practice. As noted

earlier, these outcomes are primarily focused on biophys-

ical measures, such as HgbA1c in diabetes, or blood pres-

sure in a hypertensive client, while little attention is paid to

outcomes related to client empowerment, enhanced cop-

ing, health behavior changes, and self-management of

chronic health states.


14

Ultimately, if the core of advanced practice nursing

cannot be separated from other disciplines, where can

its uniqueness be found? And how can the outcomes of

that practice be adequately and accurately measured?

Using the DNP as a catalyst for change would allow us to

shift our core to true nursing, allowing the potential for NP

care that is consistently different, yet just as essential, as

physician care. To accomplish this, the NP core must be

designed to meet current and future client needs and

capitalize on the strengths of nursing. With the aging

U.S. population, increasing prevalence of chronic illness

and global health problems, the need for health promotion

and disease prevention is readily apparent.

The core of NP knowledge, then, must explicitly include

health promotion and disease prevention. The DNP Essen-

tials specifically address clinical prevention and population

health, with clinical prevention defined as ‘‘health promo-

tion and risk reduction/illness prevention for individuals

and families’’ (AACN, 2006, p. 15). Our recommendation

takes this a step further. There is little explication in the

Essentials of the core sciences that underlie our ability to

strengthen the foundation of health promotion in clinical

practice. To attain our goal of health promotion in nursing,

we must provide a much stronger base in the physical and

social sciences. In addition, a theoretical and empirical base

that is strong in decision making and reasoning skills is also

critical. Spear (2005), in his report on the future of health

care, contends that quality providers of the future will be

those who are able to be flexible, adaptive, and responsive

to fluid clinical states. Being a good clinician will not

simply require knowledge of drug actions or standard

protocols. Quality health care requires strong clinical

thinking and flexibility.

Providing this stronger educational and practice base

requires moving beyond the current NP core of assess-

ment, pathophysiology, and pharmacology, which the

DNP Essentials do not alter (AACN, 2006). Pharmacology,

assessment, and pathophysiology are essential to NP edu-

cation, but they should build upon the base of health

promotion and prevention, not the other way around. A

reconceptualized NP core would allow for true role devel-

opment in health promotion and prevention by grounding

NP preparation in health promotion in diverse areas, such

as current theoretical and outcomes research in nursing,

health behavior change, behavioral science, exercise phys-

iology, nutrition, and the contextual considerations of

medical anthropology. Such a core would facilitate the

provision of the sophisticated health promotion and dis-

ease management care that we envision. DNP preparation

will require programs to be innovative in curriculum

development, including new courses and integration of

new curricular threads. The integration of physical and

social sciences could be in several separate courses, for

example, a basic foundational course in emerging theory

and research and an application/clinical course that focuses

on development of specific clinical skills such as exercise

prescription and managing client relapse.

Moving toward a stronger health promotion core in NP

practice and education also requires reexamining what is

taught in relation to theory and research. AACN (2005)

reports that one distinguishing feature between the DNP

and the PhD is the lessened emphasis on nursing theory in

DNP programs. While some may find this refreshing, the

distinction may be ill conceived, as midrange nursing

theories may well offer us the best guide to clinical nursing

practice (Milton, 2005). We argue that theory is critical to

the DNP but that theoretical emphasis must be middle

range and practice focused. It must also have a strong

emphasis on health promotion and prevention within the

context of wellness as well as illness. As Liehr and Smith

(1999) aptly state ‘‘. it is essential that middle range

theories emerge from the twisting of research and practice

threads by nurse scholars who are building on the work of

others and creating the future of the discipline.’’ Applicable

middle range theories should include those focused

on health behavior and health behavior change (e.g.,

DiClemente, Crosby, & Kegler, 2002). Incorporating mid-

dle range theory into DNP education will push the edge of

nursing science forward. By extending the core to health

promotion theory and knowledge of social and nursing

sciences, NPs can be considered experts in health behavior

and health behavior change and culture and diversity.

Finally, a reconfigured NP core must emphasize taxo-

nomic systems that are sensitive to nursing. If nursing is to

quantify and document the unique contributions of nurs-

ing to client outcomes, we must use a system sensitive to

nursing assessment and intervention (Haugsdal & Scherb,

2003). Continued reliance on ICD, CPT, and Diagnostic

and Statistical Manual of Mental Disorders (DSM) codes,

all of which are developed, controlled, and revised by the

medical profession and that remain medically focused,

does not serve nursing well and renders our nursing care

invisible. While NPs will need to use these classification

systems because of their use in reimbursement, NPs must

make their care visible and measurable. Only through the

use of nursing sensitive measures, such as nursing inter-

ventions and nursing outcomes classifications, can we

hope to be able to articulate what nursing contributes.

Conclusions/summary

While we have a strong history of development of the NP

role, shortcomings of current NP preparation are evident.

The DNP movement is a catalyst that can allow us to

progress beyond our current focus based on borrowed

knowledge and to uniquely expand nursing knowledge


15

and practice through true health promotion care practices.

What we propose is quite distinct from that of Mundinger

(2005; Mundinger, Cook, et al., 2000) in which being able

to practice ‘‘cross-site’’ in primary and acute care settings is

the core of the practice doctorate. It does not stand to

reason that the basis of NP practice (at the even more

advanced level of the DNP) would be focused on enabling

the clinician to work in a variety of settings. We argue that

depth rather than breadth of practice should be the hall-

mark of the DNP. We propose that a reconceptualized NP

role has a strong health promotion base and builds on

a broader core of physical and social sciences regardless of

the practice setting. Undoubtedly, different clinical expe-

riences will be needed to foster development of a broader

range of advanced health promotion skills. Typical primary

and acute care settings may not be ideal places for all of

a student’s clinical experiences in a DNP program. Stu-

dents will need to be strategically placed in a variety of

settings, including unconventional settings such as homes,

correctional facilities, and mental health settings that will

allow preceptors and students to implement a different

vision of decision making, health promotion, and disease

management not constrained by short hospital stays and

very short primary care appointments.

As we look at the key principles of NP reconceptualiza-

tion, it is critical to remember that a house is only as strong

as its foundation. DNP programs must be based on strong

initial nursing preparation (BSN), requiring us to look

more closely at the foundation of nursing education.

Mundinger (2004) argues that the ladder system is fun-

damentally flawed because of the depth of knowledge

needed for each level of practice. She says:

Because technical practice in a highly supervised envi-

ronment requires less independent decision making

and therefore less depth of knowledge, each succeeding

level of practice requires a more comprehensive under-

standing of even the basics rather than an additive set of

skills. Dispensing medications in a structured situation

like a hospital requires less knowledge of pharmacology

and pathophysiology than an independent nurse pri-

mary care provider. (p. 132)

The clinical nurse leader role proposed by AACN is

perhaps an attempt to do this, although at this point, there

is confusion about that role and some of the competencies

appear to be overlapping with the DNP. Moreover, the

focus of DNP programs should be on post-BSN preparation,

not postmaster’s preparation. Postmaster’s DNP curricula

can be developed, but it should be after the initial post-BSN

DNP curricula have been developed. This will allow exist-

ing APNs to return for the DNP, but more importantly, it

allows nursing to rethink NP practice and base the DNP

curricula on that, not on a ladder or stepping stone

approach.

It is time for advanced practice nursing to move beyond

the unfortunate labels of ‘‘physician extenders’’ and

‘‘mid-level providers’’ to embrace a uniquely nursing con-

tribution to health care. A reconceptualized core for

advanced practice nursing focused on health promotion

and disease prevention is vital. This is an auspicious

moment in NP history. We are presented with an oppor-

tunity to fundamentally rethink what the practice of NPs

should be and to design new models of NP education to fit

this reconceptualization. We feel strongly that if the pro-

fession of nursing is to go forth with the DNP, we must not

simply add to our existing MS programs nor continue

developing a variety of programs without consistent foci.

Rather, it is time to revisit the core of advanced nursing

practice. NPs can make substantial contributions to the

nation’s broken healthcare system. We must design DNP

programs that move nursing toward a new, reconceptual-

ized model of advanced practice nursing; otherwise, the

energy devoted to DNP development will be time wasted

(Meleis & Dracup, 2005). As Upvall and Ptachcinski (2007)

argue in their review of the development of the pharmacy

practice doctorate, ‘‘there was an unmet health and soci-

etal need that had been identified with the development of

the PharmD program’’ (p. 320). Nursing can fill a huge

unmet need in the area of health promotion and disease

prevention through the reconceptualization of the core of

NP practice and education.

References

Alpert, P. T., Fjone, A., & Candela, L. (2002). Nurse practitioner: Reflecting on the

future. Nursing Administration Quarterly, 26(5), 79–89.

American Association of Colleges of Nursing. (2004). AACN position statement on the

practice doctorate in nursing. Washington, DC: Author.

American Association of Colleges of Nursing. (2005). Frequently asked questions.

Position statement on the practice doctorate in nursing. Retrieved June 16, 2006, from

http://www.aacn.nche.edu/DNP/DNPFAQ.htm

American Association of Colleges of Nursing. (2006).The essentials of doctoral education

for advanced nursing practice. Retrieved March 20, 2007, from http://

www.aacn.nche.edu/DNP/pdf/Essentials.pdf

Bellack, J. P., Graber, D. R., O’Neil, E. H., Musham, C., & Lancaster, C. (1999).

Curriculum trends in nurse practitioner programs: Current and ideal. Journal of

Professional Nursing, 15, 15–27.

Blasdell, A. L., Klunick, V., & Purseglove, T. (2002). The use of nursing and medical

models in advanced practice: Does education affect the nurse practitioner’s

practice model? Journal of Nursing Education, 41, 231–233.

Buppert, C. (2003). Safe, smart billing and coding for evaluation and management: An

educational module [Computer software]. Annapolis, MD: Law Office of Carolyn

Buppert.

Burman, M. E., Stepans, M. B., Jansa, N., & Steiner, S. (2002). How do nurse

practitioners make decisions? Nurse Practitioner, 27(5), 57–64.

Campbell, L. (Executive producer). (1998). The wisdom of the willow: Capturing the

spirit of the nurse practitioner (Vol. 1) [Motion picture]. Available from Western

Media Products, P.O. Box 591, Denver, CO 80201.

Cogdill, K. W. (2003). Information needs and information seeking in primary

care: A study of nurse practitioners. Journal of the Medical Library Association, 91,

203–215.


16

DiClemente, R. J., Crosby, R. A., & Kegler, M. C. (2002). Emerging theories in health

promotion practice and research. San Francisco: Jossey-Bass.

Draye, M. A., Acker, M., & Zimmer, P. A. (2006). The practice doctorate in nursing:

Approaches to transform nurse practitioner education and practice. Nursing

Outlook, 54, 123–129.

Druss, B. G., Marcus, S. C., Olfson, M., Tanielian, T., & Pincus, H. A. (2003). Trends in

care by nonphysician clinicians in the United States. New England Journal of

Medicine, 348, 130–137.

Ford, L. C. (1997). A deviant comes of age. Heart & Lung, 26, 87–91.

Goolsby, M. J. (2005). 2004 AANP national nurse practitioner sample survey, part 1:

An overview. Journal of the American Academy of Nurse Practitioner, 17, 337–341.

Hamric, A. B., Spross, J. A., & Hanson, C. M. (Eds.). (1996).Advanced practice nursing:

An integrative approach. Philadelphia: W.B. Saunders.

Hart, A. M., & Macnee, C. (2007). How well are NPs prepared for practice: Results

from a 2004 survey. Journal of the American Academy of Nurse Practitioners, 19,

35–42.

Haugsdal, C. S., & Scherb, C. A. (2003). Using the nursing intervention classification

to describe the work of the nurse practitioner. Journal of the American Academy of

Nurse Practitioners, 15, 87–94.

Ingersoll, G. L., McIntosh, E., & Williams, M. (2000). Nurse-sensitive outcomes of

advanced practice. Journal of Advanced Nursing, 32, 1272–1281.

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. (2003). Health professions education: A bridge to quality.

Washington, DC: National Academy Press.

Johnson, J. (2007, October).APRN presentation to the American Association of Colleges of

Nursing. Paper presented at the American Association of Colleges of Nursing

meeting, Washington, DC.

Johnson, M., Bulechek, G., Dochterman, J. M., Maas, M., & Moorhead, S. (Eds.).

(2001).Nursing diagnoses, outcomes, and interventions: NANDA, NOC andNIC linkages.

St. Louis, MO: CV Mosby.

Kinnersley, P., Anderson, E., Parry, K., Clement, J., Archard, L., Turton, P., et al.

(2000). Randomised controlled trial of nurse practitioner versus general

practitioner care for patients requesting ‘‘same day’’ consultations in primary care.

British Medical Journal, 320, 1043–1048.

Liehr, P., & Smith, M. J. (1999). Middle range theory: Spinning research and practice

to create knowledge for the new millennium. Advances in Nursing Science, 21(4),

81–91.

Lynch, M. P., Cope, D. G., & Murphy-Ende, K. (2001). Advanced practice issues:

Results of the ONS Advanced Practice Nursing survey. Oncology Nursing Forum,

28(10), 1521–1530.

Martin, K. (1995). Nurse practitioners’ use of nursing diagnosis.Nursing Diagnosis, 6,

9–15.

Mauksch, I. G. (1975). Nursing is coming of age . through the practitioner

movement—pro. American Journal of Nursing, 75, 1834–1843.

Meleis, A. I., & Dracup, K. (2005). The case against the DNP: History, timing,

substance, and marginalization.Online Journal of Issues in Nursing, 10(3). Retrieved

October 4, 2005, from www.nursingworld.org/ojin/topic28/tpc28_2.htm

Milton, C. L. (2005). Scholarship in nursing: Ethics of a practice doctorate. Nursing

Science Quarterly, 18, 113–116.

Mundinger, M. O. (2004). Advanced practice nurses. The preferred primary care

providers for the twenty-first century. In J. Showstack, A. A. Rothman, & S. B.

Hassmiller (Eds.),The future of primary care (pp. 120–139). San Francisco: Jossey-Bass.

Mundinger, M. O. (2005). Who’s who in nursing: Bringing clarity to the doctor of

nursing practice. Nursing Outlook, 53, 173–176.

Mundinger, M. O., Cook, S. S., Lenz, E. R., Piacentini, K., Auerhahn, C., & Smith, J.

(2000). Assuring quality and access to advanced practice nursing: A challenge to

nurse educators. Journal of Professional Nursing, 16, 322–329.

Mundinger, M. O., Kane, R. L., Lenz, E. R., Totten, A. M., Tsai, W., Clearly, P. D., et al.

(2000). Primary care outcome in patients treated nurse practitioners or physicians:

A randomized trial. Journal of the American Medical Association, 283, 59–68.

National Task Force on Quality Nurse Practitioner Education. (2008). Criteria for

evaluation of nurse practitioner programs (3rd ed.). Washington, DC: Author.

Nicoteri, J. A., & Andrews, C. (2003). The discovery of unique nurse practitioner

theory in the literature: Seeking evidence using an integrative review approach.

Journal of the American Academy of Nurse Practitioners, 15, 494–500.

North American Nursing Diagnoses Association. (2004). NANDA nursing diagnoses:

Definitions and classification 2005-2006. Philadelphia: NANDA International.

Phillips, R. L., Dodoo, M., Jaen, C. R., & Green, L. A. (2005). COGME’s 16th report to

congress: Too many physicians could be worse than wasted. Annals of Family

Medicine, 3, 268–270.

Pulcini, J., & Wagner, M. (2002). Nurse practitioner education in the United States:

A success story. Clinical Excellence for Nurse Practitioners, 6, 51–56.

Reeves, L. M., Hermens, R., Braspenning, J., Grol, R., & Sibbald, B. (2005).

Substitution of doctors by nurses in primary care (review). The Cochrane Collaboration.

Retrieved September 2, 2005, from http://www.mrw.interscience.wiley.com/

cochrane/clsysrev/articles/CD001271/pdf_fs.html

Rogers, M. E. (1975). Nursing is coming of age . through the practitioner

movement—con. American Journal of Nursing, 75, 1834–1843.

Roumie, C. L., Halasa, N. B., Edwards, K. M., Zhu, Y., Dittus, R. S., & Griffin, M. R.

(2005). Differences in antibiotic prescribing among physicians, residents, and

nonphysician clinicians. American Journal of Medicine, 118, 641–648.

Shum, C., Humphreys, A., Wheeler, D., Cochrane, M., Skoda, S., & Clement, S.

(2000). Nurse management of patients with minor illnesses in general practice:

Multi-centre, randomized controlled trial.BritishMedical Journal, 320, 1038–1043.

Spear, S. J. (2005, September). Fixing health care from the inside, today. Harvard

Business Review, Online version, 78–91. Retrieved October 18, 2005, from

http://harvardbusinessonline.hbsp.harvard.edu/hbrsa/en/hbrsaLogin.jhtml?

ID=R0509D&path=&pubDate=null&_requestid=37607

Towers, J. (2005). After forty years. Journal of the American Academy of Nurse

Practitioners, 17, 9–13.

Upvall, M.J., & Ptachcinski,R. J. (2007).The journey to the DNPprogramandbeyond:

What can we learn from pharmacy? Journal of Professional Nursing, 23, 316–321.

U.S. Department of Health and Human Services. (2002). Nurse practitioner primary

care competencies in specialty areas: Adult, family, gerontological, pediatric, and women’s

health. Rockville, MD: Author.

U.S. Department of Health and Human Services. (2005). Physician workforce policy

guidelines for the United States, 2000-2020. Rockville, MD: Author.

Weintraub, M. (Producer). (1998). The nurse will see you now. 60 Minutes [Television

broadcast]. New York: CBS.

Weston, J. L. (1975). Whither the ‘‘nurse’’ in nurse practitioner?Nursing Outlook, 12,

148–152.


17

reconceptualizing the core of nurse practitioner education and practice

Documents