Foundations and essentials for the doctor of nursing practice

JONA
Volume 48, Number 12, pp 600-602
Copyright B 2018 Wolters Kluwer Health, Inc.
All rights reserved.

The Impact of the Doctorate of
Nursing Practice Nurse in a
Hospital Setting

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Todd E. Tussing, DNP, RN, CENP, NEA-BC
Bevra Brinkman, DNP, RN, APRN, ACNS-BC
Deborah Francis, DNP, RN, ACNS-BC
Brenda Hixon, DNP, RN, ACNS-BC, ANP-BC
Ruth Labardee, DNP, RNC, CNL
Esther Chipps, PhD, RN, NEA-BC

This article describes the initiatives
of doctorate of nursing practice
(DNP)Yprepared nurses in a large
healthcare system supporting the
DNP competencies as outlined by
the American Association of Colleges
of Nursing. The goal of this group
was to demonstrate the impact of
DNP education on the roles for nurse

administrators, advanced practice
nurses, and educators in a large health
system. Exemplars profile nurse
administrators, clinical nurse spe-
cialists, and a nurse educator.

Despite the growing numbers of
nurses prepared with a doctorate
of nursing practice (DNP), the im-
pact of the DNP in the acute care
hospital setting has not been well
described. At our institution, a work-
group of DNP-prepared adminis-
trators, clinicians, and educators
formed to examine the current
practices and complete a gap anal-
ysis comparing their current DNP
practices with the American Asso-
ciation of Colleges of Nursing DNP
competencies.1 The goal of this group
was to demonstrate the impact of
the DNP education on the enhance-
ment of roles for nurse administra-
tors, advanced practice nurses, and
educators in our setting.

Clinical Nurse Specialist
Exemplars
A major challenge faced in medical-
surgical inpatient units is the balancing

of the continuous need to increase
quality of care and patient outcomes
while simultaneously decreasing
length of stay (LOS), and overall
costs of care. To enhance patient
care and meet these challenges, a
DNP-prepared clinical nurse spe-
cialist (CNS) developed the role of
clinical coordinator (CC) for each
medical-surgical unit. The role of
the CC (see Supplemental Digital
Content 1, http://links.lww.com/
JONA/A653) is to facilitate com-
prehensive care planning, ensure
patient progress toward discharge
goals, and eliminate barriers to plan
of care and to be the consistent point
of contact with the patient and
family. The DNP-prepared CNS
used the principles of Essential:
Organizational and Systems Lead-
ership for Quality Improvement
and Systems Thinking1 during the
design of the CC role, emphasiz-
ing the importance of focusing on
panels of patients and the need to
reexamine care delivery models.
To establish and communicate the
vision of the project and to work
with stakeholders to obtain approval

600 JONA � Vol. 48, No. 12 � December 2018

Spotlight on Leadership

Author Affiliations: Administrative Director
of Nursing/Patient Care Services (Dr Tussing);
Patient Care CoordinatorYClinical Nurse Spe-
cialist (Dr Brinkman); Clinical Nurse Specialist
(Dr Francis), The Ohio State University, Wexner
Medical Center, University Hospital, Columbus;
Director of Health System Nursing Education
(Dr Hixon); Associate Director of Nursing
Evidence-Based Practice and Standards (Dr
Labardee), The Ohio State University, Wexner
Medical Center, Columbus; Associate Professor
of Clinical Nursing (Dr Chipps), The Ohio State
University College of Nursing Clinical Nurse
Scientist, Wexner Medical Center, The Ohio
State University, Columbus.

The authors declare no conflict of interest.
Correspondence: Dr Tussing, Wexner

Medical Center, University Hospital East,
181 Taylor Ave, Columbus, OH 43203
([email protected]).

Supplemental digital content is available
for this article. Direct URL citations appear in
the printed text andareprovided in theHTML
and PDF versions of this article on the journal’s
web site (www.jonajournal.com).

DOI: 10.1097/NNA.0000000000000688

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

and resources, the DNP-prepared
CNS drew upon knowledge from
the Essential: Inter-professional
Collaboration for Improving Patient
and Population Health Outcomes.1

The effectiveness of the CC role
was supported by multidisciplinary
involvement, rounding and com-
munication, and the development
of a patient-specific plan of care,
goal setting, and family involvement.
The Essential: Advanced Nursing
Practice1 provided the framework
for role development for top of
licensure practice for the CC. The
CCs are members of the patient
care team, and outcomes mea-
sured include patient satisfaction,
LOS, and all-cause readmission
rate and have revealed to be prom-
ising (see Supplemental Digital
Content 2, http://links.lww.com/
JONA/A654).

A 2nd DNP-prepared CNS
was interested in facilitating and
helping staff prioritize unit-level
quality improvement (QI) processes.
A total of 22 registered nurses (RNs)
representing 10 units were selected
to form a QI workgroup. These
RNs were provided 6 hours of course
work that included QI and an
8-hour immersion course on
evidence-based practice (EBP) (see
Supplemental Digital Content 3,
http://links.lww.com/JONA/A655).
The DNP-prepared CNS who or-
ganized and led this effort was
guided by Essential: Organizational
and System Leadership for Quality
Improvement and Systems Think-
ing,1 which emphasizes the impor-
tance of advanced communication
skills to lead practice change initia-
tives. Framing the development
and organization of this new work
group was the understanding that
sustainability of practice improve-
ments requires mentoring and edu-
cation of frontline staff. Role

modeling and teaching the impor-
tance of QI and bedside scholar-
ship to the selected nursing staff
were guided by Essential: Clinical
Scholarship and Analytical Methods
for Evidence-based Practice.1 To
date, 2 staff nurseYled QI projects
have had positive outcomes. An out-
patient wound care center changed
their nursing care delivery model
to enhance staff efficiency and im-
prove discharge teaching resulting
in improved patient satisfaction
scores (from 75% to 99%). The
2nd project on an inpatient cardi-
ology unit resulted in improvement
of patient intake/output documen-
tation over a 3-month period (from
45% to 69%) (see Supplemental
Digital Content 4, http://links.lww.
com/JONA/A656).

Administrator Exemplars
Our academic community hospital
serves a low socioeconomic minor-
ity population. As part of a long-
range strategic plan, the university
entered into partnership with the
city and local metropolitan hous-
ing authority to transform the
neighborhood into spaces for
health living and growth. A com-
ponent of the community transfor-
mation plan was to develop the 7
local schools into magnet schools
for health careers (Health Sciences
Academy). The partnership with
this community school system was
a new opportunity to form a bridge
between the academic medical
center’s health system and the local
community. To move this effort
forward, a DNP-prepared nurse
administrator served as an advo-
cate for promoting equitable health-
care (Essential: Health Care Policy
for Advocacy in Health Care1) and
exploring new avenues for health
education/promotion to improve
gaps in care for an underserved

community (Essential: Clinical
Prevention and Population Health
for Improving the Nation’s Health1).
This project required skills related
to Essential: Clinical prevention and
Population Health for Improving
the Nation’s Health1 as the project
required exploring avenues for health
education/health promotion to
improve care gaps for vulnerable
populations. The outcome from the
project was a curricular plan for
grade levels prekindergarten thru
12th grade that included medical
experiential content involving the
medical center and its professionals.

The 2nd administrator serves
as the associate director of EBP and
Standards and led an interdisci-
plinary team. This group reviewed
internal quality data, identified stake-
holders, completed a literature re-
view, and critically appraised the
evidence to develop the STAND
skin bundle (a practice bundle used
to prevent hospital-acquired pres-
sure injury [HAPI] for patients at
risk). This leader’s expertise led the
interdisciplinary team through the
7-step EBP process2 using Essen-
tial: Clinical Scholarship and Ana-
lytical Methods for Evidence-Based
Practice.1 Essential: Interprofes-
sional Collaboration for Improv-
ing Patient and Population Health
Outcomes1 provided the frame-
work as the team consisted of
nurses, would ostomy continence
team members, and a registered
dietician. Reduction of HAPIs has
broad implications for improving
the health of patients and reducing
healthcare costs using the knowl-
edge from Essential: Clinical Pre-
vention and Population Health for
Improving the Nation’s Health.1

Although data on the impact of the
STAND Skin Bundle is not avail-
able yet, the educational prepara-
tion as a DNP nurse positively

JONA � Vol. 48, No. 12 � December 2018 601

Spotlight on Leadership

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

impacted the structure and process
of this workgroup.

Educator
The DNP-prepared Director of
Education lead a multidisciplinary
team in the development of educa-
tional resources and a staff training
plan for the care for patients ex-
periencing infection and emerging
pathogens such as Ebola Virus
disease. This project required fact-
based, goal-directed health system-
wide collaboration to prepare for
an unexpected health crisis. The
Essential: Clinical Prevention and
Population Health for Improving
the Nation’s Health1 provided the
framework for understanding the
impact of emerging infectious dis-
ease and preparation for unexpected
disasters. The interdisciplinary team
reacted efficiently and quickly to

develop the care protocol and begin
training (see Supplemental Digital
Content 5, http://links.lww.com/
JONA/A657). The outcome from
the project was the development
of an institutional guideline for the
care of patients experiencing a new
emerging pathogen and education
of the care team members. More
than 100 staff members were trained
(see Supplemental Digital Content 6,
http://links.lww.com/JONA/A658;
Supplemental Digital Content 7,
http://links.lww.com/JONA/A659).

Conclusion
The growing number of DNP
graduates presents a great poten-
tial for innovation around new care
delivery models, interdisciplinary
projects, and community involve-
ment for a healthier society. Hos-
pital and health system leaders must

be open to the contribution of these
advanced practice nurses in new
and redesigned roles. The time has
come to integrate the essential com-
petencies of the DNP graduate into
healthcare system roles and com-
petencies. Nurses prepared at the
DNP level must demonstrate their
value to healthcare administrators and
nurse executives by sharing their out-
comes and engaging in empirically
based work to substantiate their value.

REFERENCES

1. American Associations of College of

Nursing. AACN Position Statement on
the Practice Doctorate. Washington, DC:
American Association of Colleges of

Nursing; 2004.

2. Melnyk B, Fineout-Overholt E. Evidence-
Based Practice in Nursing & Healthcare.
Philadelphia, PA: Lippincott Williams &

Wilkins; 2015.

602 JONA � Vol. 48, No. 12 � December 2018

Spotlight on Leadership

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.