By Linda Beuscher, PhD, GNP; Tom Cook, PhD, FNP; and Shellian D. Elliott, MA
Doctor of Nursing Practice (DNP) programs are emerging rapidly, yet scant evidence-based information addresses students perspectives of their program. This qualitative study provides a formative evaluation of students experiences of their DNP program at the end of the first year. The authors discuss current implications of these findings and make recommendations for future research.
Key words: doctor of nursing practice, DNP, DNP program
Doctor of Nursing Practice (DNP) programs have proliferated over the past 8 years, and universities continue to respond to the Institute of Medicines 2011 call to double the number of nurses with doctoral degrees by 2020.1 In 2004, four nursing schools implemented the first DNP programs. By 2012, a total of 120 DNP programs were available, with about 160 additional programs in various stages of planning.2
These DNP programs are strengthened when they are student-centered and committed to providing an innovative, high-quality curriculum that addresses students professional needs.3 Program evaluations that include students perspectives can facilitate prospective students search for a program that matches their needs. In addition, evaluations identify a programs strengths and weaknesses, helping to enhance its strategic planning process, including curriculum development.4 Formative evaluations assess a program while in progress, whereas summative evaluations assess the programs efficacy at completion. An evidence base is needed to help schools considering new DNP programs anticipate students needs, identify common challenges, and facilitate strategies to address these challenges. This study, part of a formative evaluation process utilizing qualitative methods, provides valuable information about students self-identified facilitators and challenges within their DNP program.
Review of relevant literature
The authors searched the CINAHL and Medline databases for studies published between 2002 and 2011 that evaluated DNP programs. Search terms included DNP program, nursing practice doctorate, formative evaluation of DNP programs, and summative evaluation of DNP programs. Four studies were identified (Table 1).
A formative evaluation of one DNP program using qualitative methods revealed praise for its flexibility and professional networking opportunities, but criticism about some of its coursework and about technical problems with Web-mediated aspects of the curriculum.3 Summative evaluation surveys indicated that the program helped students meet their goals and increased their involvement in professional organizations.3 Kaplan and Brown5 reported matriculating students eagerness to transform nursing practice, nursing education, and healthcare systems. Their qualitative study identified four themes: leading the way, back to the future, predictable uncertainty, and from affirmation to antagonism. Loomis et al6 utilized an innovative Internet-based survey that provided data on students rationales for choosing a DNP rather than a PhD program, the reasoning underlying their specific school choice, and their intentions for employment post-graduation. Students indicated that their career focus affected their choice of doctoral program. Specific school choice was based on compatibility, convenience, and capacity of distance-learning formats. Reilly and Fitzpatrick7 explored a curricular model often used in doctoral programs and its effect on perceived student stress and sense of belonging. The authors reported an inverse relationship between stress and sense of belonging, and suggested the use of additional educational strategies to remedy this situation.
Important research gaps exist. Information about DNP students perceptions of existing programs strengths, challenges, and merits is lacking. If sought and publicized, this information could be used to shape and improve DNP program curricula.
A formative program evaluation was done to elicit DNP students perspectives about a new DNP program. The researchers aimed to identify (1) challenges encountered by the students during the first year, (2) factors that facilitated students adjustment into the program, and (3) students perceived value of the program.
Design. Because the DNP program was new, the authors used a qualitative approach to elicit students perspectives as part of the formative program evaluation. Focus group interviews were conducted to assess DNP program components that challenged or facilitated students educational experience from the first year to the second year of the program.
Sample and setting. The study was performed at a private mid-South nursing school that offered a post-masters, full-time, five-semester DNP program. The first cohort of DNP students included 30 women and 4 men from 12 states. Most students were nurse practitioners, although some were health systems management nurses, informatics nurses, clinical nurse specialists (CNSs), or certified registered nurse anesthetists (CRNAs).
After the study was approved by the universitys Institutional Review Board, students were approached during a pre-arranged class time by two researchers who explained the study purpose and introduced the focus group moderator (not a faculty member), who then answered students questions and discussed the informed consent option after the researchers exited the classroom. Students either signed a traditional informed consent form or received a waiver of consent letter with an assumptive consent if they attended the focus group. The purpose of the waiver was to prevent study participants names from becoming available to faculty or school administrators.
A convenience sample (N = 25) from this first cohort of DNP students was recruited during intensive face-to-face classes at the end of their first year of coursework. Because the researchers were also faculty advisors who knew the students, provision of demographic data was optional (to preserve students anonymity). Of the participants who provided demographic data (n = 11), all were Caucasian and 9 were women older than 40 years. Entry levels to nursing were associate degrees (n = 3), diplomas (n = 1), and BSN degrees (n = 7).
Data collection. Participants attended one of three focus groups offered at separate times (to facilitate an appropriate group size of 7-10 participants8 and to accommodate participants time schedules). The three focus groups consisted of 8, 10, and 7 participants. Focus group interviews were conducted in a private room at the school by a trained moderator. Each session lasted 50-65 minutes. First, the moderator reviewed the purpose of the study and established ground rules. Pre-generated topic questions, reflecting study aims, were used to guide group discussions. Topic questions included categories such as challenges, professional insights, and student expectations. Examples of topic questions included What has been your biggest challenge in the DNP program? What has helped you address this/these challenges? What insights and advice do you have about the DNP program?
To ensure consistency, the same set of topic questions was used for each focus group. During each session, the focus group moderator wrote participants major points on large easel pad paper. To bring closure to each interview, the moderator summarized points discussed and allowed participants time for reflection, clarification, and validation. Immediately after each session, the moderator recorded her observations of the group interactions and patterns of communication. Each session was audio-recorded and later transcribed verbatim. All participants were able to view the major points of their focus group and then clarify, confirm, or provide additional comments via REDCap Survey, a university research database that protects anonymity and confidentiality.9 After all transcriptions were de-identified, the moderator sent them with the REDCap comments to the primary researchers.
Analysis. Descriptive statistical analysis of participant demographic data was done using the REDCap Survey. Consistent with the iterative content analysis, the researchers segmented and analyzed the data by topic to identify common ideas or categories. They examined and compared those categories for relationships among categories and clustered categories into subcategories. Both researchers independently read the transcriptions line-by-line numerous times to identify topic categories and then discussed the identified categories and subcategories. The moderators notes provided additional context.
Trustworthiness criteria. Several strategies were used to address the criteria for study trustworthiness. To promote credibility and conformability of the study findings, the authors used verbatim transcription of interview data, as well as member checking. In addition, the focus groups were moderated by the same experienced person who used the same topic questions at all three focus group sessions. The focus group moderator reviewed the transcriptions concurrently with the audiotapes to ensure data accuracy.
Participants were forthcoming in sharing insights that addressed personal, professional, and pragmatic aspects of their DNP program. Their perspectives provided a rich description of the challenges, the faculty members, and the facilitating aspects and the value of the program.
CHALLENGES OF BEING A DNP STUDENT
Time management. The greatest challenge for participants was balancing the demands of school, work, and personal life and establishing time and commitment priorities. As participants stated, Self-discipline; you can write that in all caps! You have to learn how to say no and how not to take on too much You have to keep up and on the ball Its a huge balancing act.
Several students stated that in order to find time to complete course assignments, they negotiated a flexible work schedule at their place of employment or compromised their sleep time. I just dont get enough sleep because there are so many other things to do and sleep is the one thing that I have to give up I finally asked to work 10-hour shifts versus 8 hours so I can have that extra day to work on coursework.
Time was a precious commodity. Not only did participants value their own time, but they also expected the faculty to acknowledge and value their time, particularly regarding deadlines for posting assignments electronically. For example, several
students agreed with this statement: The timing of assignments has been a significant challenge. More consideration needs to be taken and given because we are all adults with jobs. Sometimes the assignments just dont fit my busy work schedule and some assignments are just plain busy work. They [faculty] need to recognize that we are working adults, working with work-life balance issues.
Advances in teaching technologies. Adjusting to being students included facing new technologies used in academic settings. Many participants voiced this sentiment: For me, the major challenge was I had been out of school for many years. Its much different today. PowerPoint and Excel, all these things are new to me.
The Web discussion board used with the distance-learning format was new to several students. They realized one major disadvantage inherent in distance learning is the lack of real-time communication with faculty. The challenge of being at a distance is we cant talk to the instructor and not being able to ask the question right when you have the thought.
Being the first cohort. These participants were part of the first cohort of DNP students at this nursing school, which posed a unique challenge. Students stated, We are first classers; there is no baseline so we are the baseline and we really dont have anything to compare to, whereas in grad school and undergrad, you knew who were in classes before you went through and could talk [to them] Its a big unknown Being the first class, we didnt have any mentors except from faculty Its different; not all of them have been through it.
EDUCATIONAL PREPARATION OF FACULTY
Although students were able to articulate differences between the DNP and the PhD roles, they questioned the facultys knowledge of the differences between the two credentials. These comments were made: Another challenge was that PhD faculties instruct DNP students without a clear understanding of what the DNP is…I can tell a difference between the PhD- and the DNP-trained professors I would like to have DNP-trained professors and instructors.
The other expressed concern was that the faculty had a misconception that the DNP students were all NPs. Some students came from other nursing backgrounds that did not involve direct patient care. Several participants who identified their nursing backgrounds as informatics, being a CNS, or health systems management suggested that the DNP program offer two tracks of study or provide some elective courses in the curriculum to meet all students needs. Participants made these comments: One of my biggest challenges has been the mindset of the instructors being that the class is [all] nurse practitioners with hands-on care. There are several of us that do not deal with patients directly The instructors need to think in a way that we have educators, we have administrators, we have informatics people, and we have hands-on practice nurses, and that entire population needs to be thought about when the assignments are made. Maybe they need two tracks and some elective courses.
FACILITATING ASPECTS OF THE PROGRAM
Community of peers. Participants indicated that they benefitted from the diversity of backgrounds, expert knowledge, and high caliber of their classmates, as well as their ability to establish a community of peers. Participants remarked, Our classmates are invaluable and the diversity they present is a benefit. We are connecting with others, learning about each others practice. It just makes you a better clinician…Our classmates have unique skills, every single one of them.
Supportive faculty. Another important facilitating aspect of the program was the physical presence and support that participants received from the DNP faculty, including the program director, associate dean, and the dean of the school. Participants said, I think the faculty has exceeded my expectation. They have been very approachable when we had questions or concerns All of our faculty wants us to succeed. They treat us like peers and colleagues, like it is their job to support us and lift us up Its nice to know the leadership is out here and filters down. Not just the Dean but the Associate Deans are involved in our courses.
Program flexibility. Time was highly valued. As a consequence, having a flexible program that enables students to manage their time was also highly valued. One participant stated, Working full-time and Im in school full-time. Its been overwhelming at times but still manageable because of the flexibility, so you can do your work and when you have free time you can work on your course.
VALUE OF THE DNP PROGRAM
Students valued the program because it increased their competencies to deliver high-quality care, provided credibility to articulate evidence-based practice, and fostered empowerment to engage in system improvements. These insights into the programs value were reported as epiphanies termed light-bulb moments or Aha! moments. When coursework insights occurred, participants noted, It all felt like busy work until you realized that it fit into a piece of the puzzle…Now it all makes sense. But in the beginning it was frustrating Before this program I would not have been able to explain or articulate where I was coming from.
Building their toolbox. Participants realized that the coursework experience enriched their knowledge that was directly applicable to their current nursing roles and clinical work. Participants noted, They are teaching us real tools Building our box provided me with new abilities to think and to practice differently by scrutinizing research in order to make evidence-based decisions in practice Ive received access to tools I didnt know existed.
Credibility. Another important perceived value was participants newly realized credibility in their professional roles. They linked the program to increased self-confidence, both in personal and professional realms, as well as to increased respect from peers (nursing), patients, and multidisciplinary colleagues. They commented, Colleagues and other co-workers seem to be very impressed that you are in a DNP program, like it gives you credibility My patients are quite interested that I am in school as well My peers respect me more and they are impressed with what Im doing.
Empowerment. Participants felt emboldened to make changes and motivate others, and they reported an increased involvement in management projects: My confidence has increased all the way around. For example, when I go back to my work, I have made changes and have been able to be a part of the process that helps facilitate change, and that has been so empowering I am helping other people understand how the healthcare system works.
This study contributes to nursing educations evidence-based knowledge by identifying important aspects of students academic experiences. The study results can be applied to the development of high-quality DNP programs for advanced practice/informatics/CNS/health systems management nurses. Furthermore, these findings validate previous qualitative research findings reported about DNP programs. Understanding what facilitates and what thwarts students adjustment to their programs may influence their perseverance in their program, as well as effectuate changes in the curricula and student satisfaction. Finally, these evaluations provide valuable information for nursing schools aiming to ensure that their programs are student-centered and meet their students personal, educational, and professional needs.
Table 2 lists formative program evaluation results and recommendations for improvement. The DNP program has evolved as a result of this formative evaluation. Nurses with other than a practice focus were recognized as valuable professionals within the DNP program. More important, this evaluation emphasized common and divergent elements about the progressing DNP students that could be used during classroom discussion. Most striking, this formative evaluation highlighted opportunities for faculty to gain a better understanding of the DNP degree and the diversity of students pursuing this degree. The student body includes not only NPs, but also APNs who work as healthcare systems managers, informatics nurses, CRNAs, and CNSs. Hathaway et al10 encourage program leaders to explore practice that evolves from multiple views and emerging science such as informatics. Practice is defined as any form of nursing intervention that affects healthcare outcomes for individuals or populations, including direct care of patients, informatics, care management, administration of healthcare organizations, teaching, and the development and implementation of health policy.11
Another student concern was the educational preparation of some of the faculty with PhDs. Students should expect faculty to clearly understand and promote the DNP role. Nursing schools should aim to include DNP graduates for a variety of teaching positions and to provide additional training on the role of the DNP for current faculty.12
One challenge faced by DNP programs is to foster professional identity among students. Participants in this study identified one key to their success as the sense of belonging to a community of peers. Multiple opportunities to interact with classmates, other cohorts, and DNP graduates should be integrated throughout the program. Use of technology, including social media and Web-conferencing, may help students discuss their new and evolving sense of professionalism with peers and colleagues as well as address academic questions with faculty.
Limitations. Transferability of the data is only to second-year students in a post-masters, full-time DNP program. From a methodologic standpoint, the focus group members were self-selected, which may have influenced disclosure of their perspectives. This group-think phenomenon was addressed by offering participants the ability to check the focus group bullet points to ensure that their own comments were included in the data collected.
The DNP degree is in its early stages of development. As such, it is important to identify and clarify the evolution of this academic program offering a terminal degree in nursing. Particularly because of the newness of the DNP program, use of a qualitative methodology was appropriate for its evaluation. These study results validate other qualitative findings from DNP students, thereby building the level of evidence addressing early efforts to evaluate DNP programs. This study documents new and unique data about students insights into the value of their programs ability to endow a personal sense of professional empowerment and newly found professional acceptance. These insights are helpful for future DNP program planning, ongoing curricular development, and DNP faculty preparation. Future research should include qualitative interviews to include DNP graduates, as well as faculty members, in evolving DNP programs.
Linda Beuscher and Tom Cook are assistant professors at the Vanderbilt University School of Nursing and Shellian D. Elliott is the Patient Care Services Manager at Vanderbilt University Medical Center, all in Nashville, Tennessee. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.
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