Challenges and Opportunities in Nursing
Jacqueline Dunbar-Jacob, PhD, RN, Elizabeth A. Schlenk, PhD, RN, CNL, and Patricia Tuite, PhD, RN, CCNS
Objective: The objective of this narrative review of Doctor of Nursing Practice implementation is to present the background leading to the 2004 American Association of Colleges of Nursing recommendation that the Doctor of Nursing Practice degree be required for advanced practice, discuss the implementation of programs, identify challenges, and provide recommendations for the future.
Method: Both publications and organizational documents, such as white papers and position statements, were reviewed to identify the historical antecedents to the Doctor of Nursing Practice degree recommendation. A review of the status of the degree acceptance by professional organizations was conducted to identify current trends and challenges.
Summary: In 2004, the American Association of Colleges of Nursing voted to require the Doctor of Nursing Practice degree for advanced practice providers by 2015. This occurred within a broad initiative within health science disciplines to move to a practice doctorate. The need for the degree was supported by the Institute of Medicine 2002 recommendation for additional competencies in health professions education and the National Research Council 2005 recommendation that nursing create a clinical doctorate. The goal of the Doctor of Nursing Practice by 2015 has not been met, although programs are growing across the country with varying models of education. Currently nurse anesthesia requires the Doctor of Nursing Practice, clinical nurse specialists have a target date for the requirement of the Doctor of Nursing Practice, nurse practitioner recommendations are to move from the master’s level to the Doctor of Nursing Practice, but certification bodies have not required it, and nurse midwives will accept but have not endorsed a requirement for the Doctor of Nursing Practice. Nurse executives have recommended the Doctor of Nursing Practice for advanced leadership, but many health systems do not require it. There are multiple challenges to developing a pathway to the Doctor of Nursing Practice, including the multiple organizations influencing educational programs, the certification and licensure of graduates, and the employment practices by health systems. These challenges will have to be addressed to achieve the original goal of doctoral education for advanced practice in nursing.
Since 2011, enrollment in Doctor of Nursing Practice (DNP) and Doctor of Philosophy (Ph.D.) graduate nursing programs increased by almost 300%, suggesting that nursing had entered its “golden age.” This steep-growth trajectory reflects the concomitant growth in the number of doctoral programs, today exceeding 435 for the combined DNP and Ph.D. degrees. Unfortunately, the recent progress in advancing nurses in academic programs is hampered by a weakness in a competency crucial for nurses to complete their rigorous academic programs and disseminate research findings or evidence-based practice project interventions: academic writing proficiency. Since nursing curricula at the undergraduate level place lesser emphasis on the humanities, nursing students lack training in the liberal arts compendium of logic, grammar, and rhetoric necessary for effective and articulate communication and dissemination of knowledge in the field of nursing. Data generated from a recent national survey offers new perspectives on the pervasive problem of poor scholarly writing evidenced by students in graduate nursing programs: 97% of graduate papers contain grammatical errors, and only 13% of students demonstrate higher-order skills. While 81% of graduate program faculty ranked their own writing ability as “exceptional” or “highly proficient,” graduate faculty noted that 97% of the time, student papers evidenced numerous grammatical errors, such as flawed sentence structure, run-on sentences, punctuation errors, and ambiguous word choice. These data suggest that graduate nursing programs must pursue avenues to address student writing shortfalls.
The authors opine that the absence of action suggests that graduate nursing programs may be in a dilemma that parallels the metaphor and urban legend of the boiled frog, wherein acceptance of an unacceptable change occurs gradually through minor, unimportant, and unnoticed increments. Aimed at addressing this dilemma, the authors discuss the potential value of offering a customized writing course to refresh and improve students’ basic writing mechanics. A sample curriculum focuses on critical thinking, clarity, and logical flow. Nursing academicians must acknowledge the drift to low writing performance in their students, advance proficiency in scholarly writing to the top of the graduate nursing education’s agenda, and prepare nurses to achieve in nursing’s “golden age.”
Ruth Marchand Tappen, EdD, RN, FAAN, David G. Wolf, Ph.D., MSJ, MSOL, Karen Southard, RN, MHA, CPHQ, Sarah Worch, Ph.D., Janet Marchand Sopcheck
This article presents a quality improvement project involving the first organizational-level test of the effectiveness of a new U.S. Centers for Medicare and Medicaid Services (CMS) endorsed Decision Guide, Go to the Hospital or Stay Here? A Decision Guide for Residents, Families, Friends, and Caregivers. This Decision Guide can enhance resident and family knowledge about nursing home (NH) capabilities and is intended to reduce nursing home resident and family insistence on potentially unnecessary resident transfers and hospital readmissions.
The SQUIRE 2.0 guidelines were the framework for this project. A quality improvement project was conducted in 16 NHs in the southeastern United States to evaluate the effect of the resident and family Decision Guide on hospital readmission rates. Prior to implementation, the investigators provided an online orientation to the project followed by onsite training of nursing home personnel. The NHs then distributed and reviewed the Guide with residents and their family members. NH staff entered data related to readmissions and resident and family responses to the Guide into a secure portion of the project website. NH staff recorded data for three months before Guide implementation and for three months after Guide distribution. Three of the nursing homes lost their upper management team soon after study initiation and were unable to continue. A fourth did not provide complete data. In the 12 remaining facilities, the three-month mean number of readmissions dropped from 27 pre-intervention to 18.58, a 31.2% decrease. Participating facilities reported the Guide was very well received by residents and their families. The facilities’ personnel reported that most residents and family members were unaware of the scope of services provided by the nursing home, an information gap filled by the Decision Guide. They found that implementing this Guide in nursing homes was cost-effective, easy to use, and could substantially reduce readmissions. The results of this quality improvement project demonstrated a significant decrease in hospital readmission rates underscoring its potential for quality improvement in NH care and avoidance of burdensome hospital transfers.
Amosy E. M’Koma, Jamie N. Ware, Rosemary K. Nabaweesi, and Sanika S. Chirwa
Inflammatory bowel disease (IBD) is a term for two autoimmune diseases encompassing Crohn’s disease (CD) and ulcerative colitis (UC) which are lifelong diseases affecting more than 3 million adults (1.3%) in the United States. IBD is characterized by chronic inflammation of the whole digestive system which results in damage to the gastrointestinal (GI) tract. IBD often emerges during adolescence and young adulthood. Maternal morbidity includes physical and psychological conditions that result from or are aggravated by pregnancy and have an adverse effect on a woman’s health, the baby’s health or both. Some women have health challenges that arise before or during pregnancy that could lead to complications. It is recommended for women to receive health care counseling before and during pregnancy. Compared to other developed countries, the United States has the highest rate of women dying of pregnancy related complications. During the past 25 years maternal mortality has been getting worse. African American women (AAW) with and/or without IBD are dying at significantly higher rates than other groups. This is linked to several factors, i.e., systemic, institutionalized, and structural racism in health-care delivery and subsequent toxic stress from people’s lived experiences of racism, limited knowledge about healthcare system function, lack of access to healthcare, (inclusiveness and insurance policies) all of which negatively impact these patients. African Americans (AAs) are also up to three times as likely to experience severe maternal morbidity: unexpected outcomes of labor and delivery, deficient or lacking prenatal care and social determinants of health like lack of transportation, adequate employment, limited literacy, and limited healthcare access contribute to poor health outcomes. Studies on IBD patients indicate Medicaid expansion is associated with reduced rates of maternal morbidity, particularly for African American Women (AAW) and increased access to preconception and prenatal services that make pregnancy and childbirth safer for parent and baby. Herein we examine the physiological changes of pregnancy in patients diagnosed with inflammatory bowel disease and their relationship perinatal outcomes and parenthood.
Katerini Philippou, Martha Kyriakou, Nicos Middleton, Andreas Charalambous, Vasilios Raftopoulos, Marianna Constantinou, and Ekaterini Lambrinou
A comorbidity like diabetes mellitus (DM) complicates heart failure (HF) self-care management and adherence to the therapy and results poorer clinical outcomes. This study aims to examine the various factors influencing adherence to the therapy of patients with HF and DM. A systematic literature search was established in the electronic data basis PubMed, Cochrane Library and Cumulative Index to Nursing and Allied Health Literature (CINAHL) using inclusion and exclusion criteria. The search yielded eight articles. The introduction of empowerment models in the management of patients with HF and DM made patients more involved in their self-care management and their self-monitoring behavior and adherence were increased. Patients with HF and DM during their hospitalization, were less likely to receive smoking cessation counseling and blood pressure control and experienced longer length of stay. Patients with HF preserved ejection fraction (HFpEF) and DM were less likely to receive an angiotensin convertive enzyme (ACE) inhibitor or angiotensin receptor or beta-blockers and had worse blood pressure (BP) control compared with patients with reduced ejection fraction (HFrEF) and DM. Effective self-care management of patients with HF and DM seems to depend on the type and the severity of comorbid conditions and the availability of effective therapies. Adequate support to patients with HF and DM from health professionals (HPs) is important, in order to establish self-management and adherence to the therapy.