Since the establishment of the nurse practitioner role in 1965, NPs have filled gaps in health care. The founding vision of the nurse practitioner role focused on providing better care to underserved patients. The first nurse practitioners earned certificates to practice, and, as time passed and demand increased, they transitioned to a master of science in nursing (MSN).

Today, as technology improves and demands for primary care increase, a new vision of the nurse practitioner profession is becoming clear. In 2003, the Institute of Medicine published a report that called for increased preparation for health care professionals in general.¹The nursing profession offered its response: a clinical doctorate degree, the doctorate of nursing practice (DNP).

Then, in 2004, the American Association of Colleges of Nursing (AACN) recommended that all nurses seeking to be credentialed as nurse practitioners earn a DNP degree.²The phase-in date is 2015. The National Organization of Nurse Practitioner Faculties (NONPF) endorsed this recommendation, and other nursing organizations agreed that it should be an option. This degree requirement has caused much concern, discussion and even conflict within the NP community.

History
The DNP is a clinical degree intended to prepare nurse practitioners to provide quality care that matches today's health care needs. It is important to consider this new degree in context of the history of the nurse practitioner role.

In the 1980s, the MSN degree became the required degree for NP certification. NPs with certificates were grandfathered in, but new NPs had to earn a master's degree to be certified as NPs.

A doctorate of philosophy in nursing has existed for decades, and it prepares nurses who are interested in research and nursing education. While the PhD in nursing remained constant, MSN programs slowly expanded to cover all areas of expertise, to the point where the MSN degree was similar in rigor to a doctorate. Students not interested in the research component of a doctorate degree began to express their desire for a clinical doctorate focused on treating patients.

In 1979, the first iteration of a clinical doctorate, a nursing doctorate (ND), was established at Case Western Reserve University. A few other schools established a professional doctorate of nursing science (DNS, DNSc, DSN).

But the nursing profession did not have a clear understanding of either the ND or the doctorate of nursing science degree, and some people confused the ND with the MD degree. For these reasons and because the degrees required a research dissertation despite their clinical ideals, the concept of a clinical doctorate did not grow quickly.

In the 1990s, more clinical doctorate programs began cropping up that required a capstone project instead of a research doctorate. The typical capstone project involves devising a plan to put evidence into practice to improve patient care.

The newer programs that focused on clinical practice were much more popular. Seven schools in particular - the University of Kentucky, the University of Colorado, Rush University, the University of Tennessee in Memphis, the University of South Carolina, Case Western Reserve University, and Columbia University - are considered the DNP's "seven sisters," or pioneers.

A Visionary's View
Loretta Ford, NP, cofounder of the nurse practitioner role, describes the DNP as "the next logical step toward clinical excellence, leadership and political acumen in advanced practice nursing." She believes that because clinical decision-making has become increasingly complex, more education is necessary. "With the exploding knowledge base in health care, technologies and informatics, new proposed paradigms - to say nothing of population needs, demands and desires for curative, restorative and preventive health care - that additional preparation has become imperative.

"Expectations for translational research, clinical teaching and institutional leadership must be addressed by the nursing profession and its educational programs," Ford says. "The environments in which practice occurs demand leaders with vision, knowledge, communication skills, political savvy and a sense of social justice beyond that required for the one-to-one relationship of patient care.

"To be the best of team members, it is about time that nursing stepped up to the plate and earned the same status and titling that other practice professions are also requiring," Ford adds.

The DNP Landscape
As of January 2009, approximately 80 schools are offering a DNP program - and close to 200 more are preparing to start their own. In 2006, the AACN published "The Essentials of Doctoral Education for Advanced Nursing Practice," which all DNP programs must follow by 2015 in order for their graduates to be eligible for certification as NPs (Table 1).³

These "essentials" aim to ensure that DNP programs provide sufficient clinical content and are consistent across schools. After the essentials were published, all doctoral programs in nursing were required to identify themselves as a PhD or a DNP program, and to transition their content to follow their respective requirements. Most ND programs became DNP programs, and most doctorate of nursing science degrees became PhD programs.

Most programs graduate up to a few dozen DNPs a year, meaning that DNP graduates in the United States today could number in the tens of thousands.

Most DNP programs bridge from an MSN and aim to avoid replicating any education NPs earned in their master's programs. These bridging programs take 1 to 2 years to complete and contain around 40 credit hours, although programs vary.

Many of these programs are conducted online, with visits to the campus for symposia at certain times in each semester. Each program requires a project for graduation that is focused on system-level health care improvement. In the future, nurses will prepare for the NP profession by entering a 3-year doctoral program (part-time status may require more than 3 years of study). Each DNP program will contain a minimum of 1,000 clinical hours, and graduates will complete a 1-year residency to become NPs. The DNP will also be the educational requirement for certification in the three other advanced practice nursing roles: nurse midwife, nurse anesthetist and clinical nurse specialist.