Message Heard: Insights for Doctoral Program Design From Community Partners.

Developing a nursing doctoral program requires, among other considerations, thoughtful reflection on opportunities for graduates, and needs of the health-care community. To educate nurse clinicians, scientists, and leaders prepared to address complex health-care issues, colleges of nursing must engage with community stakeholders during program development. One college embraced this opportunity to dialogue through a series of semistructured focus groups and surveys to inform community partners of the developing doctoral program plan and to hear their related ideas and opinions. Themes arising from qualitative data analysis included driving forces, the value of education, and differing doctoral roles. The findings were far more enlightening than anticipated and ultimately guided the direction of program development. This study affirmed the power of meaningful dialogue with community partners to ensure a well-educated nursing workforce with the skills needed to advance nursing practice in the changing health-care environment.

Since the release of several Institute of Medicine reports in the late 1990s, improving safety-related health-care outcomes has been a national goal. Challenges in meeting this goal include the rapid development of new practice knowledge, complexity of patient care, paucity of doctorally prepared nurse leaders who can design systems of care, evaluate practice outcomes, and collaborate as members of the health-care team. The Texas average of 0.7% of doctorally prepared nurses (Texas Team Education Committee, 2017) consistently remains below the 1% national average (Altman, Butler, & Shern, 2016). As one of the largest and fastest growing states, a well-educated nursing workforce is essential to meet the complex health-care needs of the state and improve outcomes. How to achieve this goal is a challenge for colleges of nursing as they consider development of doctoral programs. In this article, we will describe the discoveries gained from meaningful dialogue with community partners and the resultant changes in our doctoral program plan.

Background

The first doctoral degree in nursing was a Doctorate in Education (EdD) offered by Teacher’s College, Columbia University and New York University in 1933. Over the next 30 years, the number of doctoral programs grew slowly to six programs nationally with degree designations including the Doctor of Philosophy (PhD) or Doctor of Nursing Science (DNS and DNSc). Establishing the National Institute of Nursing Research at the federal level in 1986 provided clear direction for developing individual nurse scientists and funding nursing research. Consequently, doctoral programs in nursing focused on preparing researchers. The American Association of Colleges of Nursing lists 130 PhD programs in 2018.

In 1965, the nurse practitioner role was first introduced. Since that time programs have proliferated. Based on evidence demonstrating quality outcomes associated with advanced practice nursing (Brooten et al., 2002), the American Association of Colleges of Nursing collaborated with the National Institute of Health, National Academy of Science, American Organization of Nurse Executives, Association of Academic Health Centers, and the Department of Veterans Affairs to determine next steps. This collaboration resulted in The Position Statement on the Practice Doctorate in Nursing supporting advanced nursing education to prepare “experts in population-based practice” and move advanced practice education to the level of the practice doctorate (American Association of Colleges of Nursing, 2007, p. 9). As a result, a clinically focused doctoral degree, the Doctor of Nursing Practice (DNP), was proposed. The DNP is designed to prepare advanced practice nurses to become clinical leaders prepared to practice at the most advanced level of nursing in today’s complex health-care system. The DNP was envisioned to primarily lead integration of best evidence in practice transforming health care to a patient-centered high-quality system (Kendall-Gallagher & Breslin, 2013). Program graduates are, therefore, in a unique position to improve patient outcomes and to advance safety.

The DNP is differentiated from the PhD through the direct application of knowledge to manage complex health issues, improve systems of care, and measure outcomes for patient populations and communities. The vision for the nursing profession is that PhD-prepared nurses build the science while DNP-prepared nurses translate the evidence in practice and evaluate the outcomes. Thus, colleges of nursing ready to develop doctoral programs have two doctoral degree options to consider in determining what is most appropriate for their individual institution and community.

Making such a program decision requires thoughtful reflection on the mission of the academic setting, the preparation of the faculty, characteristics of the student population, potential opportunities for graduates, and needs of the state or region served by the institution. In addition, nursing education programs are obligated to educate nurse clinicians, scientists, and leaders prepared to address the complex issues in the ongoing transformation of health care. To do so requires colleges of nursing engage community stakeholders in the decision-making process during program development.

The American Association of Colleges of Nursing (2016) reported that community leaders have long desired this engagement, but academic nursing has not positioned itself as a true partner in health-care transformation. Health-care leaders in the community identify this missed opportunity for alignment and often express their desire to strengthen the relationship. To take advantage of this opportunity to dialogue, the Doctoral Programs Task Force (DPTF) at a college of nursing (CON) in a rural land-grant university actively collaborated with community partners as an initial step of developing a doctoral program. The purpose of this article is to describe the unanticipated insights gained and their ultimate impact on doctoral program development from focus groups with community partners. The magnitude of impact on ultimate program design was much greater than anticipated underscoring the value of such collaboration.

Methods

Institutional review board approval was obtained for an exploratory-descriptive qualitative study with a waiver of documentation of consent. Participants were recruited from the approximately 60 known chief nursing officers and directors of advanced practice settings in proximity to three CON campuses. This convenience sample of CON community partners was invited to participate in either a focus group (in person or via collaborate phone conference) or an online survey focused on doctoral nursing programs.

For the convenience of participants, the face-to-face focus groups were conducted at each of three CON campuses throughout the state. To begin each focus group, the study information sheet was read to participants, questions encouraged, and verbal acknowledgment of consent was obtained to proceed. Two DPTF members led each focus group discussion using a semistructured interview guide. One member moderated the discussion while the other recorded the session and took field notes. Those unable to attend were encouraged to complete the online survey. Participants completing the online survey were provided the same study overview information in written form; accessing the survey acknowledged consent.

After affirming consent, the discussion moderator provided a brief overview of the emerging plan for the doctoral program to stimulate discussion. The initial plan was to open the PhD program first and the DNP program 2 years later. Select courses would be taught together; in addition, some would be open to graduate students in other disciplines. Each program would also have six credits of interdisciplinary cognates on topics relevant to the scholarly focus. Open discussion followed using the semistructured interview schedule to facilitate discussion; the online survey questions were the same (see Table 1).

Table 1.

Exemplar Focus Group and Survey Questions.

1. Could you also state why you wanted to participate in this focus group and accepted the invitation?

2. Let’s begin by exploring how nursing may be changing or evolving at your facility.

a. Tell me a bit about the preferred future for nursing at your institution.

b. As you reflect on nursing in your institution, what needs do you have for doctorally prepared nurses?

c. Do you perceive any driving forces to advance the preparation of nurses in your facilities?

d. What restraining forces have you encountered in the advance the preparation of nurses in your facilities?

3. Now, imagine that you are part of a committee of people designing a doctoral program in nursing. What do you think would be essential aspects of the program?

a. What skills or competencies are important for doctoral nursing graduates to have?

b. What are the factors that you will make sure your committee considers in designing the program?

c. What, if any, resources at this University make a doctoral program attractive?

d. What are some obstacles or reasons that nurses might be hesitant to pursue advanced nursing studies at this University?

e. What suggestions do you have for the College of Nursing to make it easier or more attractive for practicing nurses to pursue advanced study of nursing?

4. Is there anything else we have not asked that you think is important for the committee to know as we consider building a doctoral program?

Digital recordings were professionally transcribed. Data from the transcripts, survey responses, and field notes underwent an iterative analytic process to establish core categories organized into emerging themes by the DPTF. Task force members individually coded data before analyzing data as a whole committee. Categories were established through a process of constant comparison of the raw data. Findings then informed the DPTF decisions.

Results and Discussion

Nurse leaders from three regions of the state participated in focus group discussions in person, via telephone, or by completing an online questionnaire. Five participants were doctorally prepared (4 DNP and 1 PhD), 10 held masters degrees, 4 were bachelor’s prepared, and 1 did not have academic preparation in nursing. These community partners explored the changing nursing role in their facilities; based on these changes, they discussed needs for doctorally prepared nurses. Major themes arising from synthesis of statements from all participants (N = 20) were identified. Three main themes (driving forces, the value of education, and differing roles) are reported here in the language of the researchers with evidence provided in the language of the participants. An overview of each theme is provided here. In addition, the serendipitous findings that ultimately altered program development direction will be discussed.

In developing the interview schedule for the focus groups, the committee used Kurt Lewin’s (1947) Force Field Analysis Model to structure some of the discussion questions. The model was a useful aid in facilitating discussion. At the same time, we acknowledge the potential impact of the question structure on findings.

Theme 1: Driving Forces

Nursing leaders considered driving and restraining forces for advancing education within their own facilities. Subthemes for driving forces for doctoral education were voiced as the changing health-care demands, advancements of the nursing profession, and the evolution of leadership roles in nursing. Changes in national policies demanding better health-care outcomes resulted in facility changes that in turn require goal setting to push nurses toward advancing their education. The evolving role of leadership in nursing was identified as a critical driving force for advanced education. Nurses are participating in interdisciplinary teams and leading councils, committees, and research projects. Leaders noted an oversaturation of FNPs while articulating a need for nurses to continue to grow as the profession has changed over the past 20 years.

Participants specifically referenced the journey toward magnet designation as facilitating a growth in nursing education and enthusiasm for participation in nursing clinical research. Participants identified that most departments in their facilities were led by master’s prepared nurses. At the same time, they were concerned about the paucity of doctorally prepared leadership. Given the outcomes-focused evolution of health care, the participants emphasized the need to use DNPs in clinical operations in addition to requiring doctoral preparation as a minimum requirement for all Chief Nursing Officer positions.

Theme 2: Value of Education

Because the educational preparation of study participants was diverse, we did not specifically anticipate ringing support for advanced education in nursing. That assumption was incorrect. At various points throughout each of the focus groups, participants underscored the importance of advanced education in nursing with such statements as:We acknowledge the potential for bias in these results since all were aware of the stated focus group purpose. Individuals who valued education may have self-selected as attendees. At the same time, it is important to note that their comments reflected the overall social changes with regard to the nature and purposes of doctoral education. That is, the doctoral role is now focused on developing interdisciplinary scholars with the academic and social skills that prepare them to creatively solve important issues for society (Blessinger & Stockley, 2016). Participants embraced the importance of advanced education on the profession:

You don’t want to get a degree for the initials or to just check the boxes—you need to be impacting nursing practice and pulling practice forward.

People … want enrichment and a total experience.

Respect comes from education.

(Graduate) education needs to be beneficial for the community where you live.

Educate students today to be proactive and educated for the future.

What you are prepared to do needs to have meaning and substance.

Students want the synergies you get from working with other people.

(Doctorally prepared nurses) need (to) work with communities for the next level of our profession.

Theme 3: Differing Roles

In examining both the current state of and preferred future for nursing in health care, participants highlighted the evolving role of nurse leaders. The group identified competence in leadership as critical in clinical practice; executive leadership was particularly needed. Participants highlighted the evolving role of nurse leaders as critical to the future for nursing. They emphasized the needs for executive leadership as well as competent leadership in clinical practice as critical. Both the DNP and PhD roles in the practice setting were universally embraced as fundamental to improving clinical outcomes. Participants distinguished an understanding of the differing roles. The PhD was identified as significant for clinical research and education while the DNP offered a dual capacity for management and practice leadership.However, the specific roles and responsibilities for each were site dependent and differentially valued.Not all participants had experience in working within facilities with DNP- and PhD-prepared nurses, while some others were able to delineate specific job titles at their facilities differing between the two degrees. While still others noted that nurses with doctorates held only administrative roles.

—because I can see the value of each in the settings. And, you know, if we have people responsible for outcomes, and they're helping to improve outcomes—both are important. Both are important for different reasons.

DNP education prepares them to assess populations and promote innovation development to bring about practice change with hopes of improving patient care outcomes. PhD would focus on research to find solutions for healthcare initiatives that would also improve health.

cause if you’re talking about (clinical site), they’re gonna want the PhD. You’re talking about the hospital over there, they’re probably gonna want the DNP. You’re talking about the research department at the hospital, you’ll probably want the PhD.

At this current time there are not any roles at my current institution that stresses the need for a DNP or PhD role.

There are nurses with both, roles do not require that level of education

At the present time the nurses that are doctorally prepared hold administrative positions within the health system.

A DNP clinician is greatly needed not only for administrative clinical nursing positions but for advanced practice clinicians. The DNP preparation assists the nursing profession to think holistically and also assists with innovation and practice improvement.

Unanticipated Findings

Analysis of these data led to the discovery of two unexpected conclusions. First, participants universally conveyed the importance of both doctoral roles in the practice setting. Community partners voiced need for both doctoral preparation models to advance health outcomes and nursing practice. Team education was one of the foundational principles for the emerging doctoral program plan; PhD and DNP students will be educated together in specific courses and work in teams to address significant health problems. The DPTF was encouraged to discover the openness to team roles in practice, affirming the direction of the program.

The second unanticipated finding was a clear expression of an immediate need for leadership through the DNP.While the task force did not expect this, we heard the clear and urgent call for leadership in various domains of nursing.

The DNP … is what's really gonna help me get to what my goal … (of) … leadership in the clinical settings.

I’m looking at a, a DNP in order to improve clinical outcomes.

I think the DNP would help greatly enhance our novice nurses to become expert nurses. And I think they would better fulfill a clinical role and a leadership role.

The interpretation of this data was conducted with full awareness of the study limitations, including the adequate but relatively small-sample size. In addition, since different teams led each focus group variation in question and probing is assumed. Further, there was an imbalance in the preparation of participants with an overrepresentation of DNP-prepared community partners which may have influenced expressed opinions.

Implications and Conclusions

As the health-care environment continues to evolve in complexity, advancing education among nurse leaders becomes increasingly important. Academic institutions must be well informed through clinical partnerships to ensure that graduates are prepared to function within the health-care environment. The purpose of this article was to describe the impact of qualitative data collected from community stakeholders related to the development of a doctoral nursing program at a land grant university. Our intent is to illustrate the value of such collaboration early in the developmental process.

Significant insight was achieved as community stakeholders expressed the need to increase the number of doctorally prepared nurses in the clinical environment. Notably, community stakeholders identified significant roles for both PhD- and DNP-prepared nurses. Committee members were somewhat surprised to find that the participants valued knowledge discovery as well as translation of knowledge to ensure high-quality health care. In addition, barriers to achieving doctoral education were identified. The most significant of these were the length of time to acquire the degree along with the financial burden of achieving a doctoral degree. Community stakeholders also expressed concerns about time away from family related to the rigor of achieving an advanced degree.

The DPTF carefully considered the expressed needs of our community partners along with our analysis of available resources within the college. The committee recommended a staged implementation plan for doctoral programs. Based largely on the needs within our community for leadership in clinical nursing, the initial doctoral program plan was revised. Instead of beginning with the PhD program, the DNP program would launch first with both a clinical and a leadership track. The PhD program would be implemented in Phase II. However, the plan for shared courses and interdisciplinary cognates was strongly emphasized in the proposal; the committee believed that it is essential that the principle be integral in course development. Prior to conducting the focus groups, we did not foresee its potential impact on program plans. The magnitude of change was significant but appropriate because it is responsive to the community we serve.

Limitations in this study included: (a) the relatively small-sample size almost entirely representing inpatient clinical facilities, (b) differing teams of researchers running each focus group, and (c) the imbalance in the preparation of the participants (MSN, DNP, PhD) with overrepresentation of DNPs. Replication of this study is needed to extend and amplify these findings. In addition to a larger sample, inclusion of a more diverse sample of community partner may be revealing. Comparison of perspectives in diverse regions across the nation would better clarify clinical leadership needs as a whole as well as illuminate regional differences.

Multiple driving forces prompt nurses to advance their education so that they may embrace their role as leaders in the complex and evolving health-care environment. Complexity emanates from evolving technology including the electronic health record and predictive analytics to guide practice, as well as transition to an evidence-based practice model with emphasis on advancing outcomes of care. Those on the front lines of care have intimate knowledge of these changes and of the skills needed for nurses to achieve practice outcomes. They have their fingers on the pulse of health-care evolution. Therefore, data were collected from a series of focus groups and surveys in several regions of the state to capture their frontline practice knowledge and illuminate our collective view of current needs in the development of a doctoral program.

The purpose of this article was to describe the unanticipated insights—epiphanies really—garnered from focus groups with community stakeholders and clinical partners. Participants expressed a shared vision for both PhD- and DNP-prepared nurses in the clinical environment. They seek doctorally prepared nurses with skills in identifying problems, developing evidence, analyzing and applying data, and evaluating outcomes to translate new knowledge into practice (Redman, Pressler, Furspan, & Potempa, 2015; Sharts-Hopko, 2013; Udlis & Mancuso, 2015). A clear and convincing call for clinical leadership was heard significantly altering the overall plan for doctoral program development. More importantly, this study affirmed the power of meaningful dialogue with community partners to ensure a well-educated nursing workforce with the skills needed to advance nursing practice in the changing health-care environment. The value of such early collaboration with the community partners was illustrated in the ultimate direction of the program plan.

As the need for doctorally prepared nurse leaders in the clinical environment becomes increasingly important, academic programs will need to partner with clinical agencies to ensure the translation of knowledge. Information collected from these focus groups will be used in the future development of one doctoral program in Texas to better prepare nurse leaders for the clinical environment. Message heard!