Advancing the Conversation: Optimizing the Potential of the

DNP Juliann G. Sebastian, PhD, RN, FAAN

Dean and Professor University of Nebraska Medical Center

College of Nursing

Purposes • Examine the dialogue about changes in clinical practice

and the needs for nurses with practice doctoral preparation that have led us to where we are with DNP education and practice today;

• Suggest the potential impact DNP prepared nurses might have in the future and how we might create the conditions to facilitate maximum impact; and,

• Propose approaches for disseminating the impact of DNP prepared nurses that could expand and enrich their contributions to better health.

The Ground Was Shifting • University of Tennessee Health

Science Center – clinical DNSc, 1999 (Jacobs, 2008)

• University of South Carolina, ND 1999 (Morphis & Alexander)

• Rush University, ND, leadership and business of healthcare

• Case Western Reserve University – ND, advanced practice

• University of Colorado, ND, advanced practice

• New approaches at Columbia University and University of Kentucky

National Dialogue Began • AACN Doctoral Conference presentation, 2001,

Williams, Stanhope, Sebastian – “Nationally we are in the early stages of a conversation about clinical doctorates”

• Columbia University invitational conferences • NONPF Practice Doctorate Task Force, 2001-03

(Marion, Viens, O’Sullivan et al., Topics in Advanced Practice Nursing, Medscape, 2003)

• AACN Clinical Doctorate Task Force, 2002-04

Dialogue Expanded • Regional conferences around

DNP Essentials, 2005 (Lenz, 2005)

• Specialty organization discussions

• AACN Doctoral conferences • Articles in lay press &

professional publications • DNP Summits, 2012-13

– CIC (Journal of Nursing Education, August, 2013)

– AACN, 2013

Directions of the Dialogue

Why is DNP needed? Vision for the future

Educational standards Program design

Implementation issues

Impact on health & quality redesign of systems

Impact on other academic programs?

Source: © American Association of Colleges of Nursing. All Rights Reserved

Enrollments and Graduations in DNP Programs: 2004-2013

70 70 170 392 862

1,874

3,415

5,165

7,037

8,973

11,575

14,699

44 74

122 361 660

1,281 1,581 1,858

2,443

0

2000

4000

6000

8000

10000

12000

14000

16000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Enrollments Graduations

8 Source: © American Association of Colleges of Nursing. All Rights Reserved

Enrollments and Graduations in PhD/DNS Programs: 2004-2013

3,439 3,718

3,927 3,982 3,976 4,177

4,611 4,907 5,071 5,124

412 431 437 531 555 567 533 601 613 626

0

1,000

2,000

3,000

4,000

5,000

6,000

2004 2005 2006 2007 2008 2009 2010 2011 2013 2013

Enrollment Graduations

Enrollments in Both DNP and PhD Programs: 2004-2013

Source: © American Association of Colleges of Nursing. All Rights Reserved

170 392

862 1,874

3,415

5,165

7,037

,8973

11,575

14,699

3,439 3,718 3,927 3,982 3,976 4,161 4,611 4,907 5,071 5,124

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Doctor of Nursing Practice Research-Focused Doctoral

New AACN Initiatives

• Task Force on Implementation of the DNP – Clarification of clinical hours requirements – Recommendations regarding capstone

projects • Rand Corporation commissioned by AANC

Board of Directors to study barriers & facilitators to moving MSN to DNP

• APRN Clinical Training Task Force

A LOOK AT THE TRIPLE AIM TODAY AND CONTRIBUTIONS OF DNP-PREPARED NURSES

Triple Aim – an expanding concept?

• Berwick, Nolan, & Whittington (2008, p. 760) described the Triple Aim as: – “Better experience with care – Improved population health – Reduced costs”

• Focus on a “balanced” approach to these goals and to using “integration” as a means of achieving them (Berwick et al., 2008, p. 760)

Now…

• HRSA Division of Nursing 2012 Summit – Nursing in 3D: Workforce Diversity, Health Disparities, Social Determinants of Health.

• Special supplement to Public Health Reports,

June, 2014

Expanding the Sphere

Quality

Cost Health

Workforce Diversity

Social Determinants of Health

Health Disparities

Tight Linkage Between Place and Outcomes • Practice-based evidence derives from local

context and reflects local conditions, needs, preferences (Horn & Gassaway, 2010)

• More focus on local conditions is needed to ensure implementation of evidence and ongoing systemic improvements to care processes and outcomes (Glasgow, Brownson & Kessler, 2013).

Clinical Practice Access Issues

• Blumenthal & Collins (2014) estimate that 20 million people have obtained insurance coverage as of May 1, 2014.

• This suggests a need for greater access to primary care, acute and urgent care, and transitional care.

• This comes at a time when patient wait times are a serious concern.

Clinical and Population Health Quality Issues • Continued focus on eliminating errors in

health care • OIG estimated (2010) 180,000 deaths per

year due to medical errors • Major challenge now is promotion of

population health and ongoing monitoring and evaluation of population health indices

Clinical Cost Issues

• Compared with 10 other countries(Davis, Stremikis, Squires, & Schoen, Commonwealth Fund Update,June, 2014), the U.S. remains the most expensive with among the worst outcomes in safe & coordinated care, efficiency, equity, healthy lives, and access related to cost.

New opportunities in clinical & population health • Advanced specialty nursing practice is critical

to transforming the health care delivery system, whether direct or indirect practice.

• DNP preparation includes appreciation for “place” and impact of cultural norms, demographic patterns, socioeconomic conditions,

New opportunities (cont.)

• Practice influenced by payer decisions, performance expectations – value-based care

• Novel uses of technology for care delivery, emphasis on self management with consultative role of clinicians

Opportunities (cont.) • Partnerships with scientists, clinicians, patients,

families, and community members • Care systems for transitional care • Embeddedness of research into clinical care

systems • Balancing potentially competing demands of

aggregate metrics (e.g., benchmarks, dashboards, standards of care) with individualized, patient-centered care & personalized medicine informed by genetics and genomics

Vision of the Impact of DNP Graduates • Transformational – second order change • Advanced specialty nursing practice; direct or

indirect practice • Systems thinkers, system redesign • Collaborators and linkers; translational • Skilled with complexity, adaptive (e.g., Kendall-

Gallagher, Breslin, 2013) • Population health focus • Attention across time and location

- Need to identify the most important outcomes to influence and why (see Glasgow, Brownson, & Kessler, 2013)

- When does the scientist need to think like a clinician and the clinician think like a scientist? What contributions does each make to improving health care and how can these contributions be leveraged in an environment of scientific practice?

- How do nurse executives and other administrators shape environments for scientific practice?

Interdependencies between clinicians, scientists, administrators*

*From: Sebastian, J. (2014). Opportunities and Possibilities for Scientific Practice. Podium presentation at AACN Doctoral Conference.

Practice-based evidence and pragmatic trials

• Learning from heterogeneity in the clinical environment (Horn & Gassaway, 2010) – Patients and populations – Diagnostic procedures, interventions and

treatments – Outcomes

Scientist

Identifying key clinical problems in need of study Determining areas of practice that can be improved by new evidence Clinician

Administrator

Creating programs from bundles of high quality evidence Delineating implementation issues

Administrative requirements for practice-based evidence Creating systems to ensure reliability of practice-based evidence

Access to practice-based evidence Managing data privacy and confidentiality

FRAMEWORK FOR CLINICAL LEADERSHIP COLLABORATION

*From: Sebastian, J. (2014). Opportunities and Possibilities for Scientific Practice. Podium presentation at AACN Doctoral Conference.

Leadership for systems change • We assume we know what a system looks

like. • We often decry fragmented systems and call

for more care coordination. • The AHRQ Delivery Systems Committee

developed a set of domains and elements for a framework for health care organizations and systems (Pena, Cohen, Larson, Marion, Sills, Solberg, et al., 2014)

AHRQ Delivery Systems Committee Domains of Organizational and Systems Structure* • “Capacity • Organizational structure • Finances • Patients • Care processes and infrastructure • Organizational culture”

*Source: Pena, Cohen, Larson, Marion, Sills, Solberg, et al., 2014, AJPH, p. e3

Just a few examples of DNP collaborative leadership • New HRSA-funded educational option for

family nurse practitioners providing care across the continuum in rural areas (need described in Barnason & Morris, 2011)

• CMS grant for preventing unnecessary hospitalizations – Bergman-Evans, Alegent-Creighton Health System

• DNP Capstone Award winners, AACN Doctoral Conferences

• MNRS DNP Poster Awards

Dissemination Options • Policy briefs • Business plans • Annual reports • Technical assessments • Scientific and clinical journal

manuscripts • Lay publications • Web pages and online communities

Creating conditions for DNP-prepared nurses to optimize their contributions to health improvements

• Academia – Partner DNP students with PhD students,

interprofessional teams, and interdisciplinary teams – Emphasize naturalistic partnerships that exist in the

clinical environment – Consider capstone projects nested within currently

existing clinical improvement projects – Expand faculty practice & engage students with faculty

members in practice settings – Design clinical experiences collaboratively with practice

leaders (Giddens, Lauzon-Clabo, Morton, Jeffries, McQuade-Jones & Ryan, 2014)

Creating conditions for success (cont.) • Practice

– Expand academic-practice partnerships – Incorporate DNP students and graduates into

key system change initiatives – Build the business case for employing DNP

graduates and work with them to evaluate ROI

– Engage DNP students in assessing strategic priorities

Creating conditions for success (cont.) • Population health

– Engage DNP students & graduates in evaluation of large datasets and use of assessment in identifying key population health needs

– Help DNP students connect with health and social service sectors

– Engage DNP students in policy analyses and development of policy briefs

DNP GRADUATES ARE CHANGING THE FACE OF HEALTH CARE! TOGETHER WE CAN MAXIMIZE THE IMPACT OF THIS EDUCATIONAL AND PRACTICE INNOVATION.