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Clinical Scholars Review, Volume 8, Number 1, 2015 © Springer Publishing Company 13 http://dx.doi.org/10.1891/1939-2095.8.1.13

DNP/ARNPs AND ComPReheNsive CARe: ADvANCiNg CliNiCAl PRACtiCe

The Necessity of the Doctor of Nursing Practice in

Comprehensive Care for Future Health Care

Michael A. Carter, DNSc, DNP, DCC University of Tennessee Health Science Center

Phillip J. Moore, MSN, FNP-BC University of Tennessee, Knoxville

The education of nurse practitioners has undergone substantial evolution since Ford and Silver (1967) first reported on the preparation of nurses to assume the role of primary care providers for children. From this modest beginning in Colorado emerged a worldwide movement to prepare nurses to diagnose and treat patients in ways that in the past had been restricted to physicians. The early programs were not usually located in schools or colleges of nursing but rather were short-term continuing education programs. Later, nurse practitioner programs were transitioned to master’s degree programs and more recently began to evolve to Doctor of Nursing Practice (DNP) Pro- grams. The American Association of Colleges of Nursing (2014) currently lists 243 active DNP programs and 70 planned programs.

This article examines the historical context for the de- velopment of the Doctor of Nursing Practice (DNP) in comprehensive care. In doing so, there is a consideration of the substantial social and political issues in play dur- ing this evolution. Also covered are the emerging health care issues that mandate a higher level of practice prepa- ration and certification for nurse practitioners who will assume independent practices in the future.

Historical Background of the Doctor of Nursing Practice in Comprehensive Care

Nursing education in the United States has undergone almost constant evolution since the latter part of the 19th century when programs began in hospitals. Pro- grams began a very slow move into American universi- ties in the 1950s, and by the mid-1960s, new programs

emerged to prepare a new product, the nurse practitioner (Ford & Silver, 1967). The creation of nurse practitio- ner programs followed the earlier introduction of pro- grams to prepare nurse anesthetists, nurse midwives, and clinical nurse specialists. The emergence of nurse practitioner programs is interesting in that these pro- grams violated the definition of nursing adopted by the American Nurses Association in 1955. Part of that defi- nition was that nursing specifically did not include acts of diagnosis or prescription of therapeutic or corrective measures (American Nurses Association [ANA], 1955). These early nurse practitioner programs were designed specifically to prepare registered nurses to diagnose and treat patients who presented in a primary care set- ting; treatment entailed prescriptions of drugs as well as other therapeutic and corrective measures (Cockerham & Keeling, 2014).

14 Carter and Moore

of Nursing (AACN) that called for all advanced prac- tice nursing education to transition to the DNP level by 2015. This rapid proliferation of programs created new issues. Few of the programs, beyond the initial ones, were focused on nurse practitioner education. Almost all of the new programs were postmaster’s programs and did not include much, if any, of the supervised clini- cal experience needed to prepare nurse practitioners to provide comprehensive care for patients across various settings. Instead, they added additional general core courses in health policy, economics, epidemiology, and quality improvement. Also, DNP programs focused in health policy, nursing informatics, nursing administra- tion, and similar areas opened that did not have direct care as a focus. At the time of this writing, there are 243 active DNP programs and 70 planned programs listed by the AACN (2014).

Development of Competencies and Certification

In the summer of 2000, the Council for the Advance- ment of Comprehensive Care (CACC) representing the three schools with developing DNP programs; other invited schools with similar interests; and key stake holders in nursing, medicine, and industry held its first international meeting to attempt to reach consen- sus about the standards for practice at the DNP level (CACC, n.d.). The specific focus was how to distin- guish DNP graduates prepared in comprehensive care, from DNP graduates prepared in other specialties. The CACC concluded that there was a need to distinguish DNP graduates who were prepared and could dem- onstrate competency to practice comprehensive care (Carter, 2013). The American Board of Comprehen- sive Care (n.d.) was created by the CACC in 2007 as an independent organization whose purpose would be to develop a certification program for qualified DNP graduates who met this new, higher standard of care delivery. The certification program was accredited by the National Commission for Certifying Agencies in November 2011 (Carter, 2012).

The process of developing a certification examina- tion in comprehensive care required that specific com- petencies be elucidated. The Institute of Credentialing Excellence (2005) identifies two methods for identify- ing clinical competencies for health care practitioners. These are an incumbent job analysis study or logical job analysis. Developing the certification for the DNP in comprehensive care posed a challenge in that there were few DNPs with a practice in comprehensive care

Over the next 35 years, nurse practitioner educa- tion evolved from short-term certificate programs to master’s and postmaster’s programs. This evolution con- tinued as state laws began to require master’s level edu- cation for new graduates who wished to be authorized to prescribe medications and bill for services. Almost from the inception of the new master’s programs was the concern by nursing faculty and the profession that the length and depth of these programs was not suf- ficient for the level of the work expected of the new graduates (Cockerham & Keeling, 2014).

The idea of offering a doctoral degree for nurses had been around for quite a while. The profession had a his- tory of offering research doctoral degrees that began in the 1920s, but there was a rapid growth of these doctoral programs that occurred around the time that nurse prac- titioners’ education was moving into master’s degree pro- grams (Carter, 2006). The first clinical doctoral program, the Doctor of Nursing (ND), began at the Frances Payne Bolton School of Nursing at Case Western Reserve University in 1979 (Standing & Kramer, 2003). Three additional ND programs opened over the next few years (Hathaway, Jacob, Stegbauer, Thompson, & Graff, 2006). Nursing continued to evolve and respond to changes and demands of health care trends. The late 20th and begin- ning of the 21st centuries saw the development of the first work that led to the opening of the first Doctor of Nursing Practice (DNP) programs by three schools: the University of Tennessee Health Science Center in 1999, the University of Kentucky in 2001, and Columbia Uni- versity in 2005 (Hathaway, et al., 2006). The goal of these programs was to craft a clinical doctoral program for ad- vanced practice nurses who would be prepared for a level of practice that had not been previously seen.

The driving force for the creation of these programs at the University of Tennessee Health Science Center and Columbia University emerged from the sophisticated faculty practices of these schools. The faculty in nursing were engaged in practices that mirrored the other health sciences. In these practices, the nursing faculty were in- dependently diagnosing and treating patients, caring for patients across sites, billing for services, educating stu- dents, and conducting clinical research. These programs learned that the traditional master’s programs they had been offering were not sufficient in rigor or focus to pre- pare graduates for independent practice across sites in an evolving health care system (Hathaway et al., 2006).

From these early beginnings, DNP programs began opening rapidly, particularly following the 2004 posi- tion statement by the American Association of College

DNP in Comprehensive Care 15

systems, aggregate models of care for the management of chronic illness, and continuous monitoring of qual- ity of care delivered and improvements where needed (Rittenhouse, Shortell, & Fisher, 2009).

In the past, master’s level nurse practitioners were prepared to deliver care in a private office or clinic setting. Some of the most complex and challenging as- pects of health care, including medication errors and errors in communication, occur when patients transi- tion from home to hospital; from hospital to subacute care setting, such as rehabilitation centers or nursing homes; from subacute settings to home; or to palliative care (Forster, Murff, Peterson, Gandhi, & Bates, 2003). Historically, nurse practitioners did not receive the preparation to provide care across multiple health care sites, yet this is now required to reduce morbidity and mortality. Current clinical information systems do not share across these settings, even though there are new incentives being developed by the Centers for Medicare and Medicaid Services (2014), to attempt to deal with this problem. What is required of nurse practitioners, however, is that they must be competent to understand the systems of care in the various settings in which care is delivered and the ways in which patients are treated in these sites of care. Nurse practitioners who are pre- pared in comprehensive care have these competencies, which are not part of other nurse practitioner educa- tion programs (Thomas et al., 2012), because these competencies are built into the DNP programs in com- prehensive care and tested on the American Board of Comprehensive Care.

The ACA is opening the doors to care for millions of Americans who did not previously have access to care because they were uninsured or underinsured. The White House (2014) reports that about 20 million people have insurance today that did not have insurance last year under the previous system; this insurance coverage in- cludes at a minimum primary care, specialist care, hos- pital care, and preventive care. Nurse practitioners will provide care to many of the millions of new enrollees.

Evidence exists that there will be substantial new demands for care from these newly insured individuals. In 2006, Massachusetts began their move to provide insurance coverage for all the people of the state and the Massachusetts’ insurance program shares many of the key components of the ACA (Henry J. Kaiser Family Foundation, 2012). This experience by Massa- chusetts can serve as an indicator as to what the rest of the country might expect with full implementation of the ACA. The Henry J. Kaiser Family Foundation

to support an incumbent job analysis. There was other work, however, that could assist with the logical job analysis. The AACN (2006) had released its document entitled The Essentials of Doctoral Education for Advanced Nursing Practice in 2006, the same year the National Organization of Nurse Practitioner Faculties (NONPF, 2006) released their competencies for the DNP. These documents, combined with the work of the CACC, formed the basis for the logical job analysis.

Designing a national certification examination with appropriate psychometrics is a very complex un- dertaking. The National Board of Medical Examiners (NBME), an organization with a long history in devel- oping such examinations for health care professionals, entered into a contract with the American Board of Comprehensive Care to design and administer the com- prehensive care examination and to use the logical job analysis as the basis of the examination (National Board of Medical Examiners [NBME], n.d). The purpose of the examination was to “assess the knowledge and skills necessary for nurse clinicians to provide safe and ef- fective patient-centered comprehensive care” (NBME, n.d., p. 2). The first examination was administered in 2008 (Carter, 2012).

By 2011, a cohort of DNPs had graduated, were certified, and agreed to participate in the first incum- bent job analysis study of DNPs in comprehensive care (Honig, Smolowitz, & Smaldone, 2011). This job analy- sis confirmed the competencies identified by the logical job analysis that had been performed earlier by the ex- perts for the American Board of Comprehensive Care.

Emerging Health Care Trends Requiring Different Nurse Practitioners

There are several changes taking place in the health care system of the United States which call for additional preparation for future nurse practitioners. The Patient Protection and Affordable Care Act, commonly short- ened to the Affordable Care Act (ACA; U.S. Congress, 2010), is changing the way primary care is delivered, in- cluding the creation of patient-centered medical homes. This model of care is designed to improve the quality of primary care delivered in the United States and at a lower cost. The critical element of first-contact for care remains in the patient-centered medical homes, but there are new requirements that the care be con- tinuous, comprehensive, and coordinated across the care continuum (U.S. Congress, 2010). The promise is that this care will make use of new electronic information

16 Carter and Moore

help bring some logical order to conflicting plans of care by different groups and to work to bring about the desired end of life including palliative care when needed. Previous educational programs for nurse practitioners just did not provide this expertise. These are the competencies of the DNP who is prepared in comprehensive care.

Conclusion

The health care system of the United States is experi- encing several dramatic changes in the way care is de- livered, and nurses will play a major role in bringing about these changes. What is likely to occur is increased demand for primary care but not the primary care of the past. Clearly there will remain the requirements of first-contact for care by a professional who will likely work in teams of care. But no longer can this care be built on discrete episodes of care. In the future, this care will be required to be continuous across episodes, pro- vide comprehensive services including new emphasis on health promotion and disease prevention, and be highly coordinated across the care continuum. To do less fails to provide the expected quality of care and places the patient in potential harm.

Nurse practitioners have long proven their expertise in delivering primary care services to a variety of patient populations in many geographic regions. These past suc- cesses have been well documented but will not be suffi- cient for the emerging health care system. Also, the pre- vious models of nurse practitioner education will not be sufficient. New medical advances will bring challenges in helping patients navigate systems and modalities of care that are much different than what is seen today. As options and choices in care expand, so too expands the need for nurse practitioners who can help select the best options and make the best choices for the individ- ual patient. Only the diplomates in comprehensive care have the documented knowledge, skills, and abilities to be the guide to care that is demanded now and will be in even greater demand in the future.

Harm to patients through medical errors, lack of communication, and poor judgment by clinicians should be avoided at all cost. These potentially fatal errors can be avoided by nurse practitioners who possess the re- quired competencies that are a part of the DNP in com- prehensive care. With the cadre of exquisite clinicians that are being prepared and certified to provide com- prehensive care, nurse practitioners will lead the way in a reformed health care system.

(2012) indicated that by 2010, Massachusetts reported 6.3% of the population was uninsured compared to 18.4% for the rest of the United States. The people of Massachusetts are more likely to have a usual source of care other than the hospital emergency room and are more likely to have had a preventive care visit in the last year compared the rest of the United States (Henry J. Kaiser Family Foundation, 2012). In addition, there were substantial declines in all-cause mortality and mortality from causes amenable to health care following the implementation of the near universal coverage in Massachusetts (Sommers, Long, & Baicker, 2014). One of the most dangerous times for patients is the transi- tion from one site of care to another (Naylor, Aiken, Kurtzman, Olds, & Hirschman, 2011). These transitions are where the largest amount of morbidity and mortal- ity occur. The emerging new demands for care from a reformed health care system call for DNP nurse prac- titioners to be educated in new models of comprehen- sive care to assure that the lessons from the past will be shared with the rest of the nation.

Along with a reformed structure for payment, the American health care system is beginning to under- stand the many challenges posed by an aging popula- tion. There were more than 43 million older Americans in 2012, and this is expected to grow to 56 million by 2020 (U.S. Department of Health and Human Ser- vices, 2013). The Agency on Aging (U.S. Department of Health and Human Services, 2013) provides some sobering statistics: Only 42% of older Americans report their health to be excellent or very good, and most have at least one chronic condition with many having sev- eral. The most common conditions experienced by older Americans include hypertension (72%), arthritis (50%), heart disease (30%), cancer (24%), and diabetes (20%) and often more than one condition can exist at the same time for the same patient. These health problems illustrate the level of care required for this age group compared to younger age groups. Americans older than 75 years of age are substantial users of care with 23% visiting their primary care practitioner or specialist on average of 10 or more times per year, and the rate of hos- pitalization for Americans older than 65 years is three times that of younger Americans (U.S. Department of Health and Human Services, 2013).

Nurse practitioners of the future will need enhanced skills and knowledge of how to help these older Americans navigate the multiple sites of care and myriad of diverse providers and specialists. Nurse practitioners are poised to

DNP in Comprehensive Care 17

Honig, J., Smolowitz, J., & Smaldone, A. (2011). APRN survey on roles, functions, and competencies. Clinical Scholars Review, 4(1), 15–19.

Institute of Credentialing Excellence. (2005). National Commis- sion for Certifying Agencies (NCCA) standards. Retrieved from http://www.credentialingexcellence.org/p/cm/ld/fid=66

National Board of Medical Examiners. (n.d.). NBME deve- lopment of a certifying examination for doctors of nursing practice. Retrieved from http://www.nbme.org/pdf/nbme- development-of-dnp-cert-exam.pdf

National Organization of Nurse Practitioner Faculties. (2006). Practice doctorate nurse practitioner entry-level competencies 2006. Retrieved from http://c.ymcdn.com/sites/www.nonpf .org/resource/resmgr/competencies/dnp%20np%20 competenciesapril2006.pdf

Naylor, M. D., Aiken, L. H., Kurtzman, E. T., Olds, D. M., & Hirschman, K. B. (2011). The care span: The importance of transitional care in achieving health reform. Health Affairs, 30(4), 746–754.

Rittenhouse, D., Shortell, S., & Fisher, E. (2009). Primary care and accountable care—Two essential elements of delivery-system reform. New England Journal of Medicine, 36, 2301–2303.

Sommers, B., Long, S., & Baicker, K. (2014). Changes in mortality after Massachusetts health care reform: A quasi-experimental study. Annals of Internal Medicine, 160, 585–593.

Standing, T. S., & Kramer, F. M. (2003). The ND: Preparing nurses for clinical and educational leadership. Reflections on Nursing Leadership, 29(4), 35–37, 44.

The White House. (2014). Fact sheet: Affordable care act by the numbers. Retrieved from http://www.whitehouse.gov/ the-press-office/2014/04/17/fact-sheet-affordable-care- act-numbers

Thomas, A. C., Crabtree, M. K., Delaney, K. R., Dumas, M. A., Kleinpell, R., Logsdon, M. C., . . . Nativio, D. G. (2012). Nurse practitioner core competencies. Retrieved from http://c.ymcdn.com/sites/www.nonpf.org/resource/ resmgr/competencies/npcorecompetenciesfinal2012.pdf

U.S. Congress. (2010). Patient Protection and Affordable Care Act. Retrieved from http://www.govtrack.us/congress/ bills/111/hr3590/text

U.S. Department of Health and Human Services. (2013). A profile of older Americans: 2013. Retrieved from http:// www.aoa.gov/Aging_Statistics/Profile/index.aspx

Correspondence regarding this article should be directed to Michael A. Carter, DNSc, DNP, DCC, University of Tennessee Health Science Center, Memphis, TN 38163. E-mail: mcarter@ uthsc.edu

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Enhancing Nurse Moral Agency: The Leadership Promise of Doctor of Nursing Practice Preparation

^ m d

Abstract

…it is more critical than ever that we remain mindful about the demands of ‘good’ patient care.

The development of knowledgeable and skillful nurse leaders is necessary to enhance interdisciplinary

Pamela Grace, PhD, RN, FAAN

An expansive and growing body of literature documents the problem of nurses’ moral distress when they are unable to carry out actions that they perceive to be in the best interests of patients. Further, nurse leaders and educators are not always well prepared to help nurses to develop moral agency. Moral agency is the ability to provide good care and overcome obstacles to good practice. One reason for the lack of preparation is that ethics education in academia, and in ongoing nurse education, has been inconsistent or has focused more on dilemmas than the ubiquitous everyday practice issues. The purpose of this article is to discuss goals of the nursing profession, contemporary challenges to good nursing practice, and leadership from those educated as Doctors of Nursing Practice (DNP). The author argues that the proliferation of (DNP) programs, focused as they are on leadership in practice settings, presents a unique opportunity to prepare nurse leaders who are, first and foremost, skilled and knowledgeable about the ethical content of everyday nursing practice. An ‘ethics matrix’ is described and proposed as an essential base for DNP education upon which all other knowledge is built, with specific discussion of types of leadership and the relationship of transformational learning to transformational leadership.

Citation: Grace, P., (January 31, 2018) "Enhancing Nurse Moral Agency: The Leadership Promise of Doctor of Nursing Practice Preparation" OJIN: The Online Journal of Issues in Nursing Vol. 23, No. 1, Manuscript 4.

DOI: 10.3912/OJIN.Vol23No01Man04

May I stress the need for courageous, intelligent, and dedicated leadership … leaders of sound integrity. Leaders not in love with publicity, but in love with justice. Leaders not in love with money, but in love with humanity. Leaders who can subject their particular egos to the greatness of the cause. (Dr. Martin Luther King, Jr. Challenge of the new age (speech on the Prayer Pilgrimage for Freedom in Washington, DC, May 17, 1956).

Dr. King’s plea was for leadership during a troubling era. He hoped to change prevailing societal attitudes toward African American citizens of the United States (U.S.). His words remain cogent today for other settings where social justice and human dignity are at risk. For healthcare professionals, it is more critical than ever that we remain mindful about the demands of ‘good’ patient care. So many pressures exist (e.g., financial, political), and it can be expedient to neglect or even abandon professional goals and responsibilities (Bultas, Ruebling, Breitbach, & Carlson, 2016).

Additionally, nursing leaders both in academic and clinical settings must often walk a tightrope between the economic or reputational/visibility demands of the institution or school, and upholding professional goals (Gaylord & Grace, 2018; Jacob, 2009; Lown, 2007). All of these factors add to the urgency of developing nurse leaders who have the knowledge and skills to educate and support point-of- care nurses in their work and their ability to advocate for good patient care at whichever level is required: immediate, institutional, or even policy. Skills of communication and collaboration are also important. The development of

collaborations for quality, safe patient care.

Goals of the Nursing Profession

Nursing goals serve as the main anchors for understanding our ethical responsibilities…

These three domains form an ethical matrix upon which to build other essential knowledge and skills for advanced nursing practice and leadership.

…it is important to confirm the DNP role as one of ethical

knowledgeable and skillful nurse leaders is necessary to enhance interdisciplinary collaborations for quality, safe patient care.

The purpose of this article is to present an argument that doctor of nursing practice (DNP) graduates focused, as they ostensibly are, on developing the expertise for good practice, should first and foremost be prepared for ethical leadership. As noted in the American Association of Colleges of Nursing’s (AACN) document, The Essentials of Doctoral Education for Advanced Nursing Practice (2006), promulgating the DNP degree was important for several reasons. Among the reasons was that “expansion of scientific knowledge [is] required for safe nursing practice [amid] growing concerns regarding the quality of patient care delivery and outcomes. Practice demands associated with an increasingly complex health care system created a mandate for reassessing the education for clinical practice for all health professionals, including nurses” (p.4). Logically then, DNP curricula must be firmly rooted in disciplinary knowledge; an understanding of responsibilities of the nursing profession to individuals and society; and a grasp of the role of interdisciplinary collaboration in achieving quality healthcare.

The education of DNPs is an ethical undertaking because advanced nursing practice is no less about facilitating human health and well-being than are other nursing degrees. All subsequent specialty knowledge and skills needed for advanced practice should be built upon professional goals and from the unifying perspective of nursing as developed over time. The historically developed, central unifying focus of nursing has been articulated as “facilitating humanization, meaning, choice, quality of life, and healing in living and dying” (Willis, Grace, & Roy, 2008, p. E28). Further, I propose that DNPs can, and ought to, be developed as transformational leaders. Transformational leadership is the ability to empower and motivate others toward a common vision or common goals, as explained shortly (Gaylord & Grace, 2018).

Ethical aims of nurses to provide humane, quality nursing care anchored in the goals and mandates of our profession should be front and center for all our initiatives including, and most importantly, the development of nurse educators and leaders (American Nurses Association [ANA], 2010; ANA 2015; Willis et al., 2008). As a reminder, these goals are “the protection, promotion and restoration of health and well-being; the prevention of illness and injury; and the alleviation of suffering” (ANA, 2015, p. vii). The types of influences that can distract us from maintaining a focus on ethical care are well documented in the literature and seem to be increasing despite the Institute of Medicine report (2010) outlining the nursing role in assuring quality care goals (Jurchak et al., 2017; Liaschenko & Peter, 2016; Miller, 2006; Starr, 2011).

Nursing goals (ANA 2010; ANA 2015; International Council of Nursing, 2012) serve as the main anchors for understanding our ethical responsibilities and constitute the connecting fibers of what could be called an ‘ethics matrix.’ However, understanding ethical responsibilities, while necessary, is insufficient for good practice. Knowledge of ethics ‘language’ and skills is also critical. A grasp of the nuances of ethical principles and their relationship to ethical decision-making and moral agency (i.e., acting for the good) are also important as they provide a common language for team decisions. A third essential facet is the development of personal characteristics that motivate one to take action and persevere to complete needed actions.

These three domains form an ethical matrix upon which to build other essential knowledge and skills for advanced nursing practice and leadership. An additional slate of knowledge and skills deemed essential for advanced practice nursing across settings is outlined in the AACN (2006) DNP ‘Essentials’ document. These more specialized knowledge and skills, such as “Scientific Underpinnings for Practice” (Essential I) and “Organizational and Systems Leadership…” (Essential II), along with the other essentials, should be firmly rooted in and emanate from the three-domain ethical matrix to provide cohesion among them. To state this another way, the Doctor of Nursing Practice degree is first and foremost a nursing degree predicated on furthering nursing goals.

Those responsible for informing, revising, and/or developing national program and accreditation standards should consider building curricula essentials upon this ethical matrix as an integrating force. It is critical that emergent DNP leaders in the discipline are equipped with the knowledge, skills, and motivation to transform nursing practice and be instrumental in the development of ethically aware, motivated nurses. As DNP programs continue to proliferate, it is important to

Being mindful of limited resources and justice in the allocation of them is also an ethical issue.

transformative leadership…

Contemporary Challenges to Good Nursing Practice

…[business] principles can sometimes collide with human- centered goals of quality patient healthcare.

The Promise of DNP Leadership

confirm the DNP role as one of ethical transformative leadership regardless of specialty practice area.

Challenges posed by contemporary nursing practice environments require pro- active, transformative leaders who can facilitate nurses’ confidence in their ability to act for patients at the bedside, in the community, and in influencing policy making (Gaylord & Grace, 2018). There are knotty tensions between the need for cost-containment and profits in the U.S. healthcare system, and the reasons that healthcare professions and institutions exist. Stated another way, healthcare institutions, both inpatient and outpatient, exist because people have a critical need for them to assist in addressing a broad array of possible healthcare needs, not solely physical illness. The central unifying focus and nursing goals provide the broad perspective of nursing related to a focus on health and well-being that extends beyond illness.

When the provision of healthcare becomes primarily a business, corporate goals of profits can overpower human service goals, straining clinicians’ ability to primarily focus on patients and their needs (Mechanic, 2006; Rosenthal, 2017; Starr, 2011). Therefore, persons with unmet healthcare needs depend on professionals and institutions that expressly exist to fulfil these needs to actually so do.

The current situation in the U.S. is that a substantial portion of healthcare is susceptible to business principles and these principles can sometimes collide with human-centered goals of quality patient healthcare. This is not the same as saying that cost-effectiveness in healthcare is unimportant; it is of course a very important consideration. Being mindful of limited resources and justice in the allocation of them is also an ethical issue. Even countries without a profit incentive in the provision of healthcare have to ensure cost-effectiveness as a social justice issue, as discussed in detail elsewhere (Grace, 2018; Johnson & Stoskopf, 2010). However, the United States, it has been argued, does not have an integrated healthcare ‘system;’ we do not have an overarching organizing structure for healthcare delivery from cradle-to-grave or from promoting and maintaining

health to acute and chronic illness care. This situation in the United States complicates the task of healthcare professionals to further goals of good healthcare for individuals and society (Chaufan, 2015; Elhauge, 2010; Powers & Faden, 2006). What nursing can do as a profession is to highlight and try to remedy injustices that interfere with people living a ‘minimally decent life’ by informing and influencing policy at the individual level, and advocating for good patient care (Grace & Willis, 2008; Powers & Faden, 2006).

Recent moves to make a DNP degree the entry level education for advanced practice nursing, despite ongoing critiques, seem unstoppable at this point (Dracup, Crononwett, Melies, & Benner, 2005; Martsolf, Auerbach, Spetz, Pearson, & Muchow, 2015; McLeod-Sordjan, 2014; Miller, 2008). A positive aspect of this change in advanced practice preparation, with its emphasis on leadership, is the promise the movement holds for good (i.e., ethical) patient care and remediation of injustices for disadvantaged populations (as related to receiving quality healthcare, including primary care). Specifically, transformational leadership skills and characteristics are needed (Gaylord & Grace, 2018; Marshall & Broome; 2016).

Coherent and comprehensive preparation for doctoral (i.e., DNP) level practice requires both a rigorous curriculum that prepares leaders who understand the nature of their role as embedded within the profession and its goals, and essential ingredients (i.e., knowledge and skills) for leading others. Fundamental to this preparation is, as noted earlier, an education rooted in an ethics matrix.

Another way to view this idea of building ethical competence is to consider Rest’s (1982) four cognitive processes that give rise to moral agency. From an extensive review of interdisciplinary literature including that of the cognitive sciences, Rest, a cognitive psychologist, theorized four non-hierarchical, iterative, and interrelated processes that take place in the mind of a person engaged in moral decision-making with an intent to act (implying both cognitive and affective components). These processes are developmental in nature and can be cultivated. Described in numerical order below for discussion purposes, they are interactive processes and not linear in nature.

First, Rest purports that there is an ‘interpretation of the situation’ that includes ethical aspects (moral sensitivity). Second, the person draws on prior knowledge to make sense of the situation and decide what should be done (moral reasoning). Third, a decision is made among competing actions to determine which is the likely best action given knowledge of the situation (motivation). Finally, one envisions the steps to take and obstacles to overcome

A ‘Wake Up’ Call for the Profession of Nursing

Building these skills should be an imperative of the ethics of the profession.

A unifying core understanding of responsibilities of the profession coupled with fluency in ethics language and techniques can provide context, stability, and coherency…

Rooting All Curricula in an Ethics Matrix: An Ethical Imperative

Expedient actions are those based on convenience, efficiency, personal ease, or fear of

(moral character) (Grace, 2018; Rest & Narvaez, 1993; Rest, 1982; 1983). Given the preparation that advances or refines a DNP’s capacity to engage in moral agency, development of a large cohort of ethically aware and skilled leaders is possible. This cohort can in turn serve to develop the ethical confidence of students, point-of-care nurses, colleagues, and allied professionals.

If the doctor of nursing practice role is significantly one of leadership, then DNPs must understand the unique nature of their discipline and how nursing goals and perspectives are both separate from, but overlapping with, the goals of allied health professions. All healthcare professionals (self-evidently) share ultimate goals to improve the health of individuals and society, but they do so through the different lenses of their professions, and profession- specific aims. At times, these goals coalesce and require the pertinent professions to seek collaborative input to move an objective forward.

The essential set of characteristics, knowledge, and skills needed for DNP ethical leadership is captured both by Rest’s (1982) processes and the previously discussed ethics matrix, which is informed by Rest’s work. It is critical to base the development of leadership skills in nursing goals and perspectives and attendant obligations, the demands of ethical practice, and the motivation to act to improve practice. This set of knowledge and skills should serve as the basis from which other essential knowledge, as outlined in the AACN (2006) ‘Essentials’ document, is built. Building these skills should be an imperative of the ethics of the profession.

There are two senses of nursing ethics discernable in the literature. In the first sense, nursing ethics is the field of inquiry that seeks to define such things as good nursing care; the characteristics of good nurses; and how nurses should act, to name a few. This process of inquiry draws on moral philosophy and its’ derivative, professional ethics, and includes tools of analysis and synthesis. From nursing ethics, in this sense, we have developed codes of ethics. In the second sense, nursing ethics is about evaluation of nurses’ actions related to whether or not they are intentionally focused on meeting the historically developed goals of the nursing profession, as articulated earlier.

As a simple example, we can ask whether a nurse is intentionally focused on trying to provide a good for or limit harms to a delirious patient in restraining him, or is he or she restraining the patient because it is the most expedient action (Grace, 2009). Ethics in this sense is the capacity and intent to further the goals of the profession and relies on both an understanding of the nature of the services nursing provides and responsibilities to provide these services in spite of obstacles. Thus, development of DNPs as ethics leaders necessarily includes both the nurturing and fortification of personal characteristics and predispositions (sometimes referred to as virtues) and a certain level of fluency in ethics language and associated skills (e.g., situation analysis, mediation, collaboration).

A unifying core understanding of responsibilities of the profession coupled with fluency in ethics language and techniques can provide context, stability, and coherency for curricula, educational programs, and the support of point-of-care nurses. An underlying ethics matrix in which all other essential domains of content knowledge are rooted is critical (AACN, 2006). Together, the proposed unifying ethics matrix, insights from Rest’s (1982) processes of moral action, and the essential content domains and competencies of DNP programs (AACN, 2006) provide a strong basis for the development of transformational leaders and educators; those who can serve as ethics resources and build ethical decision- making and moral agency skills of students, peers, and allied professionals.

All nurses’ actions are subject to appraisal based on the extent to which they align with nursing goals and perspectives, or not. We are responsible for furthering the best interests of patients and for working toward a healthy society (ANA, 2010; ANA, 2015; Grace, 2001; 2009; Grace and Milliken, 2016). Thus, actions based on expediency or other adverse influences that divert us from the goal of patient interests are problematic.

Expedient actions are those based on convenience, efficiency, personal ease, or fear of censure rather than reactions to patient needs and concerns. For example, a terminally ill patient tells the nurse that she does not want any more aggressive treatment but is pressured by her family and the medical team to ‘continue to fight.’ The patient’s perspective and wishes are being disregarded but she is reluctant to cause a ‘fuss’ about it for her family’s sake. However, the nurse does

censure rather than reactions to patient needs and concerns.

Nurse Confidence in Ethical Decision Making: DNP as Transformational Leader

…even when nurses have had formal education in ethics in undergraduate curricula, confidence in ethical decision- making wanes over time.

Nurses need preparation to exercise moral agency and to develop the skills to collaborate with others to articulate the goals and expected outcomes of actions.

not help the patient to convey to the team her wishes because she does not want to alienate the family or physician with whom she must continue to work.

Alternatively, this nurse may not have been adequately prepared to advocate for patients or has lacked support in advocating for patient good in the past, and perhaps has even received sanctions. Other examples of expedient actions include succumbing to pressures to complete tasks in a timely manner, but in the process neglecting the psychosocial or informational needs of a patient. Milliken (2018) expands on these ideas in her recent article on ethical awareness. In upcoming discussion, I will expand upon the argument for the central role of nurse leaders and educators, who will increasingly be prepared at the level of practice doctorates, to support and empower nurse moral agency using transformative leadership skills.

Literature increasingly describes the problem of moral distress among all healthcare providers. Arguably, point of care nurses in critical or acute care settings are at highest risk for moral distress, because of their place in the healthcare hierarchy, and because they are often the ones most intimately aware of patient and family expressed preferences and worries (Robinson et al., 2014). They also do not always see themselves as having moral agency (Jurchak et al., 2017).

There is an expanding body of knowledge about nurse preparation for ethical practice, and mounting evidence that, even when nurses have had formal education in ethics in undergraduate curricula, confidence in ethical decision- making wanes over time. This is especially true as the complexity of the environment increases (Jurchak et al., 2017).

The following all point to the need for cohesive, sustained, multi-modal, ethics education and supports. First, there is increasing literature about nurse moral distress, where nurses experience a sense of powerlessness and disquiet when unable to do what they perceive as ‘the right thing.’ Second, over ten years of unpublished data from evaluations of a mandatory graduate ethics course (n = 447) point to the efficacy of this type of educational offering in building confidence in their moral agency (Grace, 2018). Third, a recent analysis of reasons that staff nurses and advanced practice nurses (total n = 67) wanted to join a year-long clinical ethics residency for nurses (Jurchak et al., 2017) highlighted the desperate need for more ethics education.

Nurses may feel that they are silenced (Malloy et al., 2009) or perceive that their concerns are not heard and considered (Peter, Lunardi, & McFarlane, 2009; Taran, 2011). Thus, to sustain confidence in one’s moral agency and capacity for ethical decision-making in contemporary practice settings, more than formal ethics content knowledge is required. Traditional content, such as history of biomedical ethics; moral theory and principles; and analytic decision-making techniques are all valuable tools. Possession of these tools, while foundational for moral agency, is insufficient for consistent action to address problems (Grace & Milliken, 2016; Robinson et al., 2014). Nurses need preparation to exercise moral agency (Liaschenko & Peter, 2016) and to develop the skills to collaborate with others to articulate the goals and expected outcomes of actions.

Knowledgeable and ethically competent educators and institutional leaders are important. Such leaders understand the goals and perspectives of the profession as well as those of allied professionals. They anchor their actions as educators, mentors, resources and supporters in the goals and perspectives of the profession. They employ the set of tools described above to gather more information; gain clarity about the issues; and to explore nuances of a situation. Further, they have leadership skills that empower others to develop their moral agency.

Transformational leaders in nursing understand professional goals and the ethical warrants of nursing practice…

Ethically Skilled Educators and Leaders: A Role for Doctors of Nursing Practice

…it is incumbent on the profession to ensure that the ongoing development of the DNP role reflects the ethical foundations of the profession…

Transformational leadership skills are those most apt to develop the confidence and skills of others to achieve mutual goals (Marshall & Broome, 2016; Gaylord & Grace, 2018). Transformational leaders in nursing understand professional goals and the ethical warrants of nursing practice and are essential to development of nurses who are confident in their ethical skills and exercise them on behalf of good patient and healthcare. That is, transformational leaders are those who can develop and support the moral agency of nurses at all levels and areas of practice.

Well-designed DNP programs will develop graduates who have gained such transformational leadership skills and the know how to continue to develop these abilities. Such graduates will be both visionary about what is good practice and have the ability to support it. From essential domains of knowledge, they will understand the big picture complexities of institutions; how to influence policy; design supportive work environments; and the necessities of good patient care. Using a sound understanding of nursing ethics,they will move seamlessly among these areas to educate and support others to develop moral agency. I believe that good practice is equivalent to ethical practice, as noted above, because good practice aims to meet the goals of patient and societal health, wellbeing, and the relief of suffering.

As highlighted in the AACN Essentials of Doctoral Education for Advanced Nursing Practice (2006), doctoral education in nursing has typically been of two main types, research focused and practice focused. Prior to 2004, a few universities offered practice doctorates in nursing as distinct from research-intensive doctorates but not under a uniform title, leading to confusion (AACN, 2004; Reid Ponte & Nichols, 2013). The AACN Position Statement on the Practice Doctorate in Nursing (2004), among other sources, presented several reasons for rapidly developing more DNP programs.

There is a growing perception of the need for more highly skilled nurse leaders. “Increased knowledge and skills [are becoming crucial] for clinical and administrative leadership across services and sites of healthcare delivery” (AACN, 2004, p.2). This requires advanced preparation in areas not typically covered in- depth in current nursing master’s programs. There is an ongoing faculty shortage and DNPs could fill a gap (Brown & Crabtree, 2013). Moreover, strong leadership is needed in institutional and other clinical settings.

Master’s programs in nursing are already credit-intensive so moving to the DNP as entry level for advanced practice would better match program requirements, credits, and time with the credential earned. These credentials would also better match professional clinical doctorates in other disciplines (e.g., pharmacy, dentistry, physical/occupational therapy). Additionally, the DNP degree provides an avenue of scholarship and leadership that is not as acutely focused on empirical research as is contemporary PhD study (Grace, Willis, Roy & Jones, 2016), leaving room for development of sorely needed quality, educational, and safety improvement projects.

“Preparation at the practice doctorate level includes advanced preparation in nursing, based on nursing science, and is at the highest level of nursing practice” (AACN, 2004, p. 3). The AACN statement also proposes that DNP preparation will improve the image of nursing. Additionally, PhD prepared nurse scholars are increasingly focused on developing research trajectories and pursuing necessary funding and resources. Such worthy aims can be all consuming and lessen available time for teaching (Grace, Willis, Roy & Jones, 2016) adding to the existing faculty shortage; this represents an area for DNP prepared nurses to make an important contribution.

Since 2004 DNP programs have proliferated and now far outnumber programs offering a research focused PhD in nursing. There are “303 DNP programs are currently enrolling students at schools of nursing nationwide, and an additional 124 new DNP programs are in the planning stages (58 post-baccalaureate and 66 post-master’s programs)” (AACN, 2017, p. 3). Regardless of one’s perspective about whether the move to the DNP as entry-level advanced practice is a good thing for the profession, evidence suggests that in the coming years there will be a rapid increase in the number of those prepared at this level. Thus, it is incumbent on the profession to ensure that the ongoing development of the DNP role reflects the ethical foundations of the profession, and historical as well as contemporary reasons for its existence (Grace, 2001; 2018).

Transactional leadership is, arguably, the most commonly seen in healthcare settings and is managerial in nature.

Underlying, implicitly or explicitly, the achievement of each [DNP] essential is ethical expertise and leadership qualities.

Types of Leadership

Transformational leadership is aimed at change.

Relationship of Transformational Learning to Transformational Leadership

There are eight aspects of knowledge and expertise considered ‘essential’ for DNP graduates to possess in the current (first iteration) AACN (2006) document. Underlying, implicitly or explicitly, the achievement of each essential is ethical expertise and leadership qualities. However, how to achieve the essentials is still at least partially left to each school or college. In the following section, I outline what is known about leadership and leadership qualities and propose that the nursing profession should focus on developing ethically savvy, transformative leaders and that DNP programs are an appropriate medium for this initiative.

Definitions of leadership vary according to author, style, and purpose. A synthesized definition, useful for nursing, is that leaders are effective in moving a group of people toward a shared goal (Curtis, de Vries, & Sheerin, 2011; Sullivan & Garland, 2010; Weihrich & Koontz, 2005). In a review of studies on the psychology of leadership, it is defined as “a process of social influence in which one person is able to enlist the aid and support of others in the accomplishment of a task or objective” (Chemers, 2001, p. 8580). Regarding the DNP role, I define leadership as both the capacity to anticipate and envision good practice using nursing goals, knowledge, and perspectives to shape ultimate aims, and the use of knowledge, skills, and expertise to motivate and empower moral agency in others. Inherent in this definition is the possession of an ability for critical questioning of personal motivations and a willingness to critique care environments for the ability to provide good care.

While leadership types and characteristics necessarily overlap, two main types of leadership are evident in contemporary literature. These are ‘transactional’ and ‘transformative.’ Transactional leadership is, arguably, the most commonly seen in healthcare settings and is managerial in nature. In transactional leadership there is a power differential, the leader can direct actions based on a sort of ‘bartering’ system (Gaylord & Grace, 2018). For example, if you accomplish the task I have given you in a timely fashion, I will give you a bonus. Within transactional leadership there are three sub-types (Howell & Avolio, 1993). One focuses on reward, one focuses on negative feedback, and the third allows things to proceed without much direction but, when things go wrong, steps in to remediate. Transactional leadership, then, tends to be task-oriented rather than innovative, prescient, and creative (Howell & Avolio, 1993; Murphy, 2005).

Transformational leadership is aimed at change (Gaylord & Grace, 2018). The change may involve all actors including the leader and the environment. Transformational leaders “energize and motivate their followers to achieve their goals, share their visions, and embrace empowerment” (Grimm, 2010, p.76). Transformational leadership is relationship based, and empowers others to actions of which they had not thought themselves capable (Bass & Avolio, 1994).

Characteristics that are common in transformational leaders include: magnetism; possessing internal locus of control (i.e., see themselves as accountable for actions); offers inspiration; cognitively curious, questioning assumptions that are made and willing to be personally challenged by others; and the capacity to focus simultaneously both on the big picture and the needs of followers. In so doing, these leaders act as mentors and educators (Chemers, 2010; Cummings et al, 2010; Grimm, 2010). Among the goals of transformative leadership, related to the nursing profession, is the development of moral agency (i.e., motivation and ability to engage in ethical actions on behalf of self and others) in nurses (Blacksher, 2002; Liascheno & Peter, 2015).

The concept of transformative learning is also important to develop transformational leaders. Those who aim to empower others need to know how it is possible to help others transform themselves into moral agents. Theories of transformational leadership have developed within the education discipline. Mezirow (2009) recognized this transformational side effect of good education after his wife returned to school to advance her education. Further research led to the development of the concept of transformational education; education that permits a person to develop, as such:

Transformational learning is defined as the process by which we transform problematic frames of reference (mindsets, habits of mind, meaning perspectives) – sets of assumption and expectation – to make them more inclusive, discriminating, open reflective and emotionally able to change (Mezirow, 2009, p. 95).

Nursing ethics is at the base of everything we do as nurses.

Conclusion

Author

References

One can deduce from this that the process of transformational learning is complex, takes time, and may involve some disorientation. Transformational education aims to broaden perspectives and develop increasing comfort with nuances and ‘grey areas.’ My colleagues and I discovered that our carefully designed, multi-modal, eight hour per month, 10-month long program, the Clinical Ethics Residency for Nurses (CERN), had a transformational effect upon our graduates, as evidenced in their discussions and evaluation of the program (Grace, Robinson, Jurchak, Zollfrank, & Lee, 2014; Robinson et al., 2014). They also evidenced decreased moral distress (Robinson et al., 2014) and increased their moral agency. Participants included both point of care and advanced practice nurses. End of program essays (analysis in process) also demonstrated that the majority of participants experienced personal and professional transformation.

Questions remain about what is needed to ensure that DNP education prepares graduates to be transformational leaders; how can transformational leadership be maintained; and how can transformational leadership translate to practice and education settings? A starting place to find answers is to reinstitute the importance of an understanding of the profession of nursing's origins, evolution, and reasons for continued existence as a separate entity from other healthcare professions. We have a unique and central unifying focus on humanizing the healthcare environment and facilitating “meaning, choice, quality of life, and healing in living and dying” (Willis et al., 2008, p. E28). Perhaps even more important is that we continue to grow all of our education; curriculum development; research; and practice initiatives or directives from a nursing ethics matrix.

The rapid proliferation of DNP programs means that, in the future, there could be a substantial cohort of persons prepared to provide ethics leadership in whatever clinical, institutional, or educational setting they are located. As transformational leaders they will be sensitive to the ethical nature of all nursing and healthcare practice and able to communicate this to colleagues, students, and important others as an essential starting point. They will facilitate the development and moral agency of students, peers, and interdisciplinary colleagues.

Anecdotally, many nursing faculty still view ‘ethics’ as an esoteric topic that can be taught only by those with philosophy or applied ethics backgrounds. I believe this is a fallacy. Nursing ethics is at the base of everything we do as nurses. It is helpful to have knowledge of ethics language and skills in ethical decision-making, but acquiring this knowledge is not as difficult as sometimes supposed. It is critically important that DNP curricula, along with the expected knowledge and skills of graduates, are developed with the professional moral imperative for individual and social good in mind. We need to situate graduates so that they can envision, refine, facilitate, and meet nursing goals from a nursing perspective.

Pamela Grace, PhD, RN, FAAN Email: [email protected]

Pamela Grace is an Associate Professor of Nursing and Ethics at the William F. Connell School of Nursing Boston College. She is an experienced critical care and advanced practice nurse and educator. She holds a PhD is in Philosophy (1998) with a concentration in medical ethics. She has written and presented extensively on nursing and healthcare ethics. Her book, Nursing Ethics and Professional Responsibility in Advanced Practice, (2018) is now in its 3rd edition and is used internationally as a guide to ethics in advanced practice settings.

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