In 2004, membership of the American Association of Colleges of Nursing (AACN) voted on and adopted a position statement supporting the doctor of nursing practice (DNP) degree as the most appropriate degree for preparing advanced-practice registered nurses (APRNs) to enter clinical practice.* At the same time, AACN members voted to approve the position that all master's programs that educate APRNs to enter practice should transition to the DNP by 2015. However, at this time, less than a quarter of the schools with APRN programs have fully met this goal. We employed a mixed-method approach (surveys and qualitative interviews) to investigate schools' progress toward the adoption of the DNP for preparing APRNs for clinical practice and the barriers and facilitators to that progress. Specifically, we analyzed data from a comprehensive survey of schools fielded annually by the AACN, an online survey developed and fielded specifically for this project, as well as qualitative interviews with deans and directors of 29 nursing schools.
Schools' Program Offerings
Schools continue to adopt the DNP, both as an option to be completed for practicing master's-level APRNs (the MSN-to-DNP) and as an entry-level APRN option for those with a bachelor of science in nursing (BSN) degree (the BSN-to-DNP). Overall, the number of schools with a DNP program has grown tenfold in the past seven years. The AACN Annual Survey of Baccalaureate and Graduate Nursing Programs revealed that, of 400 schools offering some level of APRN education in 2013, 98 (25 percent) had active BSN-to-DNP programs and 229 (57 percent) had MSN-to-DNP programs. Data from the RAND/AACN online survey, which obtained responses from two-thirds of nursing schools with APRN programs and was fielded six months later than the AACN Annual Survey, suggest even more movement toward BSN-to-DNP programs. Incorporating data from the online survey, we estimate that 30 percent of schools have BSN-to-DNP programs for APRNs (rather than 25 percent), and that 11–14 percent of schools have fully transitioned to the BSN-to-DNP and do not offer the terminal MSN, up from just a single school with that status in 2010. An additional 77 schools that are currently offering only MSN-level APRN education report in the 2013 AACN Annual Survey that they are planning a BSN-to-DNP. In the RAND/AACN online survey, 63 such schools report planning to offer a BSN-to-DNP for APRNs by 2016. Another 33 schools that currently have such programs report planning more for additional APRN roles, and eight schools without any current APRN education also plan to offer BSN-to-DNP programs by 2016. Overall, in the next several years, the percentage of schools (with any APRN education) that have a BSN-to-DNP program for at least one APRN group could approach 50 percent.
Nevertheless, the MSN remains the predominant entry-level APRN program for schools of nursing. Seventy percent of schools that educate APRNs currently offer only the MSN. Furthermore, 65 percent of schools that do adopt the BSN-to-DNP continue to retain their MSN programs—and for schools that simultaneously offer both options, the MSN programs currently enroll roughly three times as many students, on average. As noted above, schools' plans suggest further expansion of the BSN-to-DNP in the near future. And a further 27 percent of schools with only MSN-level APRN education responded to the RAND/AACN survey that they plan on closing their MSN programs. Yet even with these planned changes, the MSN would still remain the majority form of APRN education.
This diversity in approach toward APRN education was reflected in our survey data and discussions with schools. Based on conversations with nursing school leaders and responses to the RAND/AACN Online Survey, we find that school representatives largely value the content of the DNP education in preparing nurses for the rising challenges of the U.S. health care system, but differ in ways they seek to offer this content to students. A number of schools can be considered “early adopters” of the DNP and have enthusiastically moved forward by adopting the BSN-to-DNP and discontinuing their MSN programs. Other schools, even among the school representatives who find significant value in the DNP, have not moved as aggressively toward full adoption of the DNP, often developing a DNP program while maintaining their MSN programs. A third type of school could be described as “traditionalists” and have decided not to adopt the BSN-to-DNP.
Facilitators and Barriers Toward Offering the BSN-to-DNP
Through our investigation, we uncovered a number of barriers and facilitators important in schools' decisions to offer the BSN-to-DNP. First, we uncovered several structural factors associated with schools' offering choices. Controlling for all factors simultaneously, autonomous or freestanding schools, schools in the West and Midwest, and schools in states with a high density of existing nurse practitioners (NPs) were considerably more likely to offer BSN-to-DNP programs. Though we don't fully understand the mechanisms underlying these factors, autonomous or freestanding schools of nursing appear to face fewer institutional barriers and constraints to offering the BSN-to-DNP.
With respect to contextual factors (factors more malleable and unique to each school), we found the strongest facilitators toward offering the BSN-to-DNP to be enthusiasm and support among the school's key faculty, administration, and decisionmakers. Underlying this support was typically an endorsement of the value of the DNP content. Fully 93 percent of survey respondents offering or planning on offering the BSN-to-DNP cited the “value of the [DNP] education in preparing for future health care needs” as very important or critical to their decision. The AACN endorsement of the DNP also factored strongly in many schools' decisions to offer the BSN-to-DNP, as did, in some cases, a desire to expand into doctoral-level education.
How that level of support then translated to schools' program choices was influenced by a number of barriers and conditions that appeared key to their ultimate decisions. Key conditions governing schools' choices are the fact that the DNP is still an option and not a requirement for APRN entry into practice, coupled with local demand for DNP-level education among students and employers as perceived by each school. With some exceptions, most schools did not perceive strong employer awareness of the DNP in particular. Practicing APRNs expressed strong interest in the DNP, and the convenience of completing the degree while working, in many cases, has led to a high rate of adoption of the MSN-to-DNP. Some incoming students expressed strong interest in the BSN-to-DNP (perceived demand for the DNP among students was rated as a facilitator by some survey respondents and as a barrier by others) while others were interested in the MSN—and thus, it was typically a complex calculation among schools whether to meet both simultaneously or to offer only the BSN-to-DNP and accept the potential loss of some students to other schools offering the MSN.
With respect to specific barriers toward adopting the BSN-to-DNP, many schools, particularly those that are part of larger public systems (rather than freestanding or autonomous schools of nursing), cite internal and institutional barriers, such as obtaining approval from numerous levels of leadership, boards, and regional bodies. Cost, faculty resources, securing clinical sites and preceptors, and managing capstone projects were also barriers cited by schools (although in some cases, particularly concerning faculty and clinical sites, schools may not have been able to isolate barriers particular to the DNP versus those relevant to APRN education in general). While these barriers can usually be overcome when schools and program directors are highly motivated, full adoption of the DNP will likely continue to be incremental and incomplete unless the certifying and accrediting bodies require the DNP for entry into APRN practice and the benefits of the DNP are more widely recognized by students and employers.
Based on these findings, we derive the following conclusions as well as recommended action steps that could help AACN achieve its goal.**
- The DNP continues to expand steadily.
- The MSN remains the dominant pathway for APRN entry-into-practice education, though there is some limited movement toward replacement with the BSN-to-DNP.
- There will likely be two tracks toward the DNP for the near future (defined by schools' planning horizons): a single-step process (BSN-to-DNP) and a two-step process (BSN-to-MSN followed by an MSN-to-DNP at a later date).
- The value of the added content of the DNP education is almost universally agreed-upon.
- Requirement of the DNP for certification and accreditation is an important factor in schools' decisions.
- From the point of view of the nursing school leaders we spoke to, demand for DNP-educated APRNs on the part of employers is generally nondifferentiated between the MSN and the DNP, albeit with a few exceptions. Student demand for the DNP on the part of currently practicing APRNs appears robust, given the proliferation of MSN-to-DNP programs. Student demand for the BSN-to-DNP is more variable—with some seeking the BSN-to-DNP and others seeking the MSN.
- Freestanding or autonomous nursing schools are more likely to offer the BSN-to-DNP, a finding that may be associated with fewer institutional barriers faced by these schools.
- Identifying sufficient number of clinical sites is sometimes cited as an issue, but it is unclear how much this concern is specific to the DNP.
- Faculty and administrative support within the university is, more often than not, a strong facilitator toward offering the BSN-to-DNP.
- Many schools cite faculty resources as constraints to the development of DNP programs, sometimes noting the capstone project as a particular resource challenge.
- Costs and budgetary concerns are a key barrier to many schools—particularly those that are not freestanding or autonomous schools.
- Schools noted additional specific challenges in operating and sustaining BSN-to-DNP programs, some of which the AACN could help them overcome. We do not see evidence of a significant risk to these programs' being discontinued once begun.
The AACN should:
I. Conduct, and collaborate with others to conduct, outcome studies of DNP practice to better understand the impact of DNP graduates on patient care.
II. Provide outreach and data to help employers and health care organizations understand the added competencies and capabilities of DNP-educated APRNs.
III. Focus on understanding and documenting successful strategies in overcoming barriers to offering BSN-to-DNP programs of departments or divisions within larger universities, since they face greater hurdles or barriers to offering BSN-to-DNP programs.
IV. Document and showcase examples of collaborative partnerships between schools and hospitals or other health care organizations for the purpose of providing clinical practice sites.
V. Provide greater clarity and guidance related to requirements for the capstone project.
VI. Continue with ongoing efforts to assist schools in overcoming challenges to offering the BSN-to-DNP.
* We acknowledge that the DNP is a terminal degree for all areas of advanced nursing practice and not just the four APRN roles. The DNP degree is designed to provide education to advanced nursing practice roles, which include those focused on practice at the aggregate, systems, or organizational level. For the purposes of this study, however, RAND was commissioned by AACN to focus on only the APRN master's degree program transition to the DNP.
** RAND does not hold an official position in favor of, or against, this goal.
This work was sponsored by the American Association of Colleges of Nursing (AACN). The research was conducted by RAND Health, a division of the RAND Corporation.