Women’s health nurse practitioners (WHNPs) provide specialized direct, advanced practice care to women across the lifespan from adolescence through end of life. The National Certification Corporation reports that as of December 2021, over 26,000 are currently certified as WHNPs through their organization.1 Who among these certified WHNPs has a passion for clinical research? Who among them has obtained or considered a terminal doctoral degree with a research focus?
Terminal doctoral degrees are becoming increasingly common for clinical practice disciplines, including nurse practitioners (NPs). The Doctor of Nursing Practice (DNP) degree is the terminal degree in nursing for clinical practice. The Doctor of Philosophy (PhD) degree is the terminal research degree for most disciplines, including nursing. PhD-prepared nurses generate new knowledge and science, while DNP-prepared nurses use existing knowledge to affect practice change through leadership and implementation.2 Both are important to provide evidence-based, quality women’s healthcare, but both are not equally represented among WHNPs. The authors of this article, as WHNPs with PhD degrees, provide insight into the need for more WHNPs prepared at the PhD level to generate nursing science for improving women’s healthcare and health outcomes. Challenges and strategies to meet this need are discussed.
According to the American Association of Colleges of Nursing, 7,841 doctoral degrees were conferred in nursing in 2018, but only 11.3% were research-focused PhD degrees and the remaining 88.7% were DNP degrees.3 This disparity may be in response to the goal of having the DNP be the terminal degree for NPs by 2025.4 Regardless of the reason, the low numbers of PhD-prepared nurses result in a very narrow pipeline for future nurse scholars to generate science. Considering that WHNPs represent a small percentage of all certified NPs in the US, the pipeline for those with women’s health expertise is extremely limited. According to investigators, this imbalance may have unintended consequences for the generation of nursing science.5 Given the proliferation and popularity of DNP degrees compared to PhD degrees among WHNPs, a fundamental question in the women’s health sphere is who is generating knowledge specific to women’s health? If it is not WHNPs, then others in that space, including MDs or non-NP PhD researchers, become the source of new knowledge generation. Although non-WHNP researchers produce valuable science in this area, the unique contribution of PhD-prepared WHNPs is a mix of advanced practice nursing knowledge and skills, expertise in women’s health and gender-related care, and a holistic approach to patient care that is grounded in the core values of the nursing profession. This specialized skill set allows PhD-prepared WHNPs to conduct research that is clinically relevant and translatable to multiple patient care settings.
NPs in academia
Many PhD-prepared WHNPs work in faculty roles, and the ongoing retirement of US nursing faculty has created a situation where there are reduced WHNPs who generate knowledge specific to women’s health. Additionally, this has contributed to reduced research mentorship for the next generation of women’s health scholars.6,7 Mentorship and a good match between a PhD student and faculty member has been identified as important to successful degree completion.8 With declining numbers of PhD-prepared WHNP faculty, students have less opportunities for mentorship and exposure to advanced practice nursing role models in the generation of women’s health science. The DNP role was created to prepare advanced practice registered nurses (APRNs) such as NPs, certified nurse midwives, and nurse anesthetists for roles in clinical leadership. However, the national faculty shortage of nursing academics in the US has created opportunities for NPs with a clinical doctorate to assume faculty roles that were once reserved for those with a PhD.
Recent researchers discussed the importance of PhD-prepared nurses in academia, highlighting that the role of an academic nurse extends beyond teaching and includes knowledge generation through the conduct of research and application of evidence for practice.9 Additionally, nurse academics who are generating research and disseminating their scholarship provide opportunities for students to witness and participate in the generation of research that will become the evidence base for practice. The proliferation of DNP-prepared faculty has exposed students to practice-based leaders but has limited student interaction with research-focused faculty, especially in more narrowly focused areas such as women’s health.10
It is clear that the numbers of PhD-prepared nurses across all specialties, including PhD-prepared WHNPs, are declining. Innovative solutions are needed to address this issue in multiple ways.
Dual DNP–PhD degrees
One option to increase the number of PhD-prepared WHNPs is to invest in a dual doctoral degree, the DNP–PhD degree.11 Combining the roles of clinical expert and rigorous researcher has been successfully established within the practice of medical doctor MD–PhD programs. There are approximately 90 MD–PhD programs nationwide and over 5,000 MD–PhD-prepared clinicians who are clinical experts generating new knowledge and translating the best evidence directly into improving patient care.11 The dual academic preparation allows for generation of clinical questions into thoughtful and relevant research studies that will provide evidence to guide healthcare. This can shorten the timeframe from knowledge generation to clinical practice change. With this combination of skills, DNP–PhD-prepared WHNPs are uniquely positioned to address clinical problems and design and interpret research to improve practice. Currently, only a few DNP–PhD programs exist in the US, but more schools of nursing are exploring the development of this option. Hopefully, there will be growing opportunities for nurses interested to pursue this dual degree. Individual programs differ, and some students can enter as post baccalaureate or post masters, with time to degree based on individual circumstances.
Although dual DNP–PhD degree programs can add additional PhD-prepared nurses, practical considerations limit the attainment of dual degrees. Even with streamlined degree pathways, the programs require extensive coursework. The time commitment and financial resources required may not be attainable for many individuals, even if partial funding is available.11 Other challenges are the time required to complete research and the time allotted by universities to complete degrees. If students need to take a leave of absence or slow down their progression for personal or employment-related issues, they may extend their time in the program beyond the set limit and not complete the degree.8,11 Nevertheless for the motivated nurse, this can be an academic approach that combines the best of both worlds of nurse practitioner and researcher.
PhD program considerations
Nurses who already have masters or DNP degrees as WHNPs may consider enrolling in a PhD program to pursue additional competencies in conducting research and roles as nurse scholars. PhD program completion is time-intensive. For WHNPs who are trying to balance a clinical position, personal commitments, and doctoral coursework, this can be a challenging endeavor.8 Increased financial support for full-time programs that promote completion in a shorter timeframe is one possible solution, including internal university funding for fellowships or the federally funded Nurse Faculty Loan Program.12 However, not all individuals can or want to access these resources, reduce their hours in their clinical role, and/or leave their outside employment. Another approach is a streamlined baccalaureate to a PhD program that creates opportunities for students earlier in their careers.10 In this approach, nurses who know they want to conduct research can obtain a PhD degree and then complete a WHNP program while working in an academic other nurse scientist role.
Whichever degree approach they choose, mentorship has been identified as important to PhD student success.8,10 PhD students need to have opportunities to engage in a variety of scholarly activities such as team science, clinical research, publication, conference presentations, and teaching.8,10 Mentorship in these areas can help PhD students envision future roles and experience different possibilities associated with a research doctorate. Working with a PhD-prepared WHNP during graduate studies allows students access to a visible mentor in both the clinical practice and research roles. However, this can be challenging due to the low numbers of PhD-prepared WHNPs and students may need to seek mentorship outside of their own academic institution.
Nurse scientist appointment
The opportunity for a nurse scientist appointment may attract some WHNPs to obtain a PhD degree. Nurse scientists often work in an academic hospital or health system setting on research initiatives that have been identified at the setting. They may have a joint faculty appointment in a school of nursing, which could bridge the academic–clinical divide and allow the WHNP to be a research leader in the field of women’s health. WHNPs in this role are integral to leading and implementing research programs specific to women’s health, which may involve interprofessional teams and varied methodologic approaches.13,14 A nurse scientist appointment, in which the PhD-prepared WHNP is generating the research and helping to translate the findings into practice, helps promote translational research and is an excellent opportunity to collaborate with DNP-prepared nurse colleagues to implement evidence-based recommendations.13
Target WHNP students
Women’s health nurse practitioner programs, whether at the masters or doctoral level, share the same primary foci of all advanced practice programs. The curriculum is heavily focused on didactic content and skill development at the advanced level, including attainment of required clinical practice hours and demonstration of competencies related to their population focus. This does not need to preclude promoting the role of WHNPs as research scientists. WHNP students should have the opportunity to engage with PhD-prepared WHNP faculty, participate on research teams, and envision themselves as both expert clinicians and scientists.
Conclusion
A more robust pipeline of WHNPs obtaining PhD degrees and pursuing the role of nurse scientist to generate new discipline specific knowledge is critical. As the DNP becomes the standard for entry into practice across all NP specialties, including women’s health, fewer students are choosing to advance their educational preparation at the PhD level. It is imperative to create opportunities for WHNPs and WHNP students to learn about opportunities in research, to have mentorship from WHNPs with PhD degrees, and to explore new educational pathways to support PhD education. The knowledge generated for the women’s health specialty is strengthened when researchers have expertise as WHNPs.
Heidi Collins Fantasia is Associate Professor and Department Chair for the Solomont School of Nursing, Zuckerberg College of Health Sciences at the University of Massachusetts in Lowell and a board-certified WHNP. Sandi Tenfelde is Associate Professor in the Marcella Neihoff School of Nursing at Loyola University in Chicago, Illinois, and a board-certified WHNP who maintains a clinical practice at a Federally Qualified Health Center in Chicago. Allyssa L. Harris is Dean and Professor in the College of Nursing at Prairie View A&M University in Houston, Texas, and a board-certified WHNP. The authors have no actual or potential conflicts of interest in relation to the contents of this article.
Womens Healthcare. 2023;11(1):23-26. doi: 10.51256/WHC022323
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