HEALTH CARE SYSTEMS in the United States have Nursing's response was a shift in the national dialogue:

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1 NATIONAL AGENDA FOR ADVANCED PRACTICE NURSING: THE PRACTICE DOCTORATE PATRICIA CLINTON, PHD, CPNP, FAANP,* AND ARLENE M. SPERHAC, PHD, CPNP, FAANt The purpose of this article was to provide the background and rationale for the practice doctorate in nursing. The American Association of Colleges of Nursing's Position Statement on the Practice Doctorate in Nursing, approved in October will be discussed. Outlined are 1 some of the changes that will be needed in education. regulation. and advanced practice. I Common questions and concerns that advanced practice nurses have, including titling, salary, and transitioning to the doctor of nursing practice degree, will be addressed. (Index words: Advanced practice nursing; DI\IP; Education; Practice doctorate) J Prof Nurs 22:7-14, Elsevier Inc. All rights reserved. HEALTH CARE SYSTEMS in the United States have Nursing's response was a shift in the national dialogue: become increasingly complex, ineffective, ineffi from status quo to the realization of expertly trained cient, and unwieldy. In tum, health care providers have clinicians who could contribute not only to the become frustrated with health care systems unable management of health and illness in an individual, a to meet the demands of informed consumers for cost family, or a community but also to the health care effective quality health care. Complex problems require delivery system by means of precise organizational, innovation and creative thinking. The report of the economic, and leadership skills. Pew Health Professions Commission (1995) sparked nationwide discussions within and among health care professions that led to reflection on how to reconceptualize Action the education of health care providers. The It is important to recognize the clarion call issued by report called for a new and different learning environ the 10M (2001) in its landmark work, Crossing the ment for all health professionals-an environment that Quality Chasm: A New Health System for the 21st called for partnerships with technology, health care Century, as preliminary to the work of the American systems, and the government to forge new alliances. An Association of Colleges of Nursing (AACN) and the interdisciplinary summit convened by the Institute of development of the practice doctorate as the appropriate Medicine [lam] (2001) also recognized the need for credential and level of education for advanced practice new ideas and novel solutions for the education of nursing. The 10M report called for new directions in health professionals. The 10M identified core compe and emphasis on the education of health care profestencies that all health care providers should possess. sionals, regardless of discipline, by identifying core competencies that include a focus on patient-centered care, an interdisciplinary approach to health care 'Clinical Associate Professor and Director of the Master's Program, management, the use of evidence-based practice, con University of Iowa College of Nursing, Iowa City, lao tinuous quality improvement, and the incorporation of tprofessor and Coordinator of the Pediatric Nurse Practitioner informatics to manage and understand the wealth of Program, Rush University, Chicago, IL. data available to clinicians (lam, 2003). The 10M Address correspondence and reprint requests to Dr. Clinton: reports, as well as data on the changing roles of Clinical Associate Professor and Director of the Master's Program, University of Iowa College of Nursing, Iowa City, IA advanced practice nurses (APNs), influenced discussion patricia-clinton Uiowa.edu by national nursing leaders of the need for changes and /$ - see front matter refinements in nursing education. Generally, nursing JOurnal of Professional Nursing. Vol 22. No I Qanuary-February), 2006: pp Elsevier Inc. All rights reserved. doi: I0.1016/j.profnurs I2.007

2 leaders agree with the 10M recommendations and are attempting to address them through careful planning, curriculum redesign, and development of new models for nursing education and practice. Responding in a proactive manner, nursing leaders proposed that the practice doctorate be accepted as the terminal practice degree for nurses who wish to have their major focus in clinical practice. Many factors in addition to the 10M and AACN reports influenced this decision. The complexity of health care systems requires nurses to be fluent in the language and practice of leadership and management. Knowledge is expanding rapidly and requires skills of retrieval and use perhaps as much or greater than the generation and acquisition of knowledge. Rationale Other disciplines, such as audiology and physical therapy, have established practice doctorate programs as entry points into practice. These practice doctorate programs provide the skills necessary to synthesize and apply knowledge to clinical populations. Nursing is unique in that there are many levels of clinical practice from technical nursing to advanced practice nursing within the profession. The skills needed by an APN require an ability to adapt to various populations, collaborate with other health care professionals, coordinate care across settings, and synthesize and apply new knowledge to the practice setting. The acquisition of that knowledge and skill set is difficult to achieve in educational programs, as we now know them, without adding credit hours to programs that are already overloaded. The current status of master's degree in nursing (MSN) programs that prepare a nurse practitioner (NP) is comparable with that of the practice doctorate in other disciplines such as audiology and physical therapy. The practice doctorate in nursing would provide parity in credentialing with these disciplines and allow nurses to be recognized as full participants in health care decision making. Although those in the four current advanced practice nursing roles (clinical nurse specialists, nurse anesthetists, nurse midwives, and NPs) are most often thought of as the appropriate group to assume the new degree and may emerge as the first to seek the degree, the degree is in no way exclusive to them. The intent is that nurses may seek the practice doctorate in any area that addresses the health care outcomes for individuals and! or populations across clinical and community settings. This includes direct care of individual patients, management of care for individuals and organizations, identification and management of information, and the development and implementation of health policy. In other words, clinicians, administrators, and informaticists are all in practice roles and deserve to be recognized with a degree that reflects their knowledge and skills. Background The development and current status of the practice doctorate were the result of thoughtful planning and coordination of many organizations and institutions. Early recognition of the need for a true practice doctorate developed in several locations. For example, the University of Kentucky opened a program in 2001 to further develop the knowledge and skills that NPs would need to assume leadership positions within institutions and state and federal agencies. A practice doctorate program proposed at Columbia (Mundinger et al., 2000) was in response to findings from research that indicated the need for additional knowledge and skills by NPs to meet the needs of clients with complex health problems in diverse settings and to ensure quality and access to care by NPs. The 10M report, as well as other information in the literature pertaining to the educational needs of APNs and changes in the health care system, precipitated much discussion at the AACN doctoral conference in January This discussion was followed by a teleweb conference hosted by the National Organization of Nurse Practitioner Faculties (NONPF), with the MCN participating in February In December 2003, a national forum on the practice doctorate was held in Washington, DC, which was attended by 25 national nursing organizations and 16 academic health centers (see list of participating organizations and institutions in Table 1). The purposeful collaboration of numerous professional organizations and academic institutions Signaled a united effort among nursing leaders for the development and implementation of the practice doctorate (Sperhac &. Clinton, 2004). For a more complete understanding of the history and time line, refer to the AACN's Position Statement on the Practice Doctorate in NurSing, October 2004, which is available at its website ( Late in October 2004, nursing education leaders were asked to vote on the MCN August 2004 draft position statement on the practice doctorate in nursing. Two issues were presented for action to the membership: (1) to endorse the position statement as presented and (2) to approve that the transition to the practice doctorate be completed by Sixty percent of the members present approved both motions. Most recently (Iune 2005), the American Association of Nurse Anesthetists met to discuss the AACNi recommendations and how they might affect nurse.j 1 anesthetist education. Although generally agreeing on the move to the practice doctorate, participants supported a 25-year timeline rather than the 2015 deadline, advocated by the AACN. In addition, a series of regional meetings sponsored )1 by the AACN would have been scheduled from.".1 September 2005 to January 2006 to discuss and critique.:, the draft of the essentials document recently completed \ by the Essentials Task Force. These meetings will provide opportunities for continued discussion and debate among relevant stakeholders..'.: '1..

3 In~ ~ - _-.Table I. Participating Organizations and Institutions: National Forum on the Practice Doctorate in Nursing Organizations American Academy of Nurse Practitioners American Academy of Nurse Practitioners Certification Program MCN American Association of Critical Care Nurses American Association of Nurse Anesthetists American College of Nurse Midwives American College of Nurse Practitioners American Nurses Association American Nurses Credentialing Center American Organization of Nurse Executives American Psychiatric Nurses Association American Public Health Association Public Health Nursing Section Association of Community Health Nursing Educators Association of Women's Health and Neonatal Nurses Commission on Collegiate Nursing Education Intemational Society of Psychiatric Nursing National Association of Clinical Nurse Specialists National Association of Nurse Practitioners in Women's Health National Association of Pediatric Nurse Practitioners National Conference of Gerontological Nurse Practitioners National Council of State Boards of Nursing National League for Nursing National League for Nursing Accrediting Commission NONPF Pediatric Nursing Certification Board Institutions Case Western Reserve University Columbia University George Washington University Oregon Health Sciences UniverSity Purdue University Rush University University of Colorado Health Sciences University of Illinois at Chicago University of Iowa University of Kentucky University of Massachusetts, Worcester University of Michigan University of South Carolina University of Tennessee Health Science Center University of Washington Yale University Transitioning to the Doctor of Nursing Practice With the approval of the position statement, task forces were formed to address the curriculum and the plan for implementation of the practice doctorate. The objectives of the task forces are to further define and to operationalize the recommendations contained in the position statement. Content in a practice doctorate program will include information that provide students with the knowledge and skills to practice competently in the present yet appreciate that practice will change based on evolving clinical evidence. Students will be provided with information that will help them think Critically, retrieve knowledge and recognize deficiencies, and identify methods and/or resources to remedy the deficiencies. Skills in data collection, data mining, and pattern recognition will be taught, enabling students to adapt to meet the evolving demands of practice. Initial Steps Continuing changes in the health care system necessitate changes in education and practice. Planning for the practice doctorate is based on review of materials such as practice delineation studies, the standards and guidelines from professional organizations, and recommendations from program evaluations. The practice doctorate acknowledges the extensive educational preparation that NPs and other APNs require and will communicate that degree of preparation and accountability to the public. The Position Statement on the Practice Doctorate in Nursing of the AACN (2004) operationalizes many of the recommendations that were outlined in the report of the 10M (2003). Significant recommendations clustered together around the following themes: Core content; Titling; Transitioning for master's-prepared nurses; and Accreditation of programs. Recommendations Core Content The AACN (2004) recommends using the template Essentials of Master's Education for Advanced Practice Nursing (AACN, 1996) as a model to develop a similar document for the doctor of nursing practice (DNP). Broad competencies appropriate for all DNP graduates would be supplemented by specialty competencies for each area of specialty practice. The broad or core competencies (see Box 1) reflect a universal but not prescriptive foundation for developing curricula and programs of study for the DNP. It is evident that the list of core essentials allows for diversity in programs to address the specific focus and need for knowledge and skills in specialty areas. This approach can thus accommodate informaticists, educa tors, NPs, administrators, and others in advanced practice nursing roles. Expert leadership and advanced clinical and organi zational skills will enable graduates to initiate policy and programmatic efforts, mobilize interdisciplinary teams, collaborate to solve complex clinical problems, and address clinical issues. The DNP will be expected to provide visionary leadership for the practice of nursing. Other recommendations of the position statement of the AACN (2004) suggest that additional course work in I 'I [1 L......====~~~- ~ ~~~

4 Box 1 Essential Areas of Content for Practice Doctorate Programs: Scientific underpinnings for practice Advanced nursing practice Organization and system leadership/management, quality improvement, and system thinking Analytic methodologies related to the evaluation of practice and the application of evidence for practice Use of technology and information for the improvement and transformation of health care Health policy development, implementation, and evaluation Interdisciplinary collaboration for improving patient and population health care outcomes pedagogical methodologies would better prepare DNP graduates for the role of nurse educator should it be an identified career goal. Titling Titling is a concern expressed by many NPs who believe that creating a new title will only add to confusion. The recommendations put forth by the AACN address this issue by directing that one titlethe DNP-be used to represent practice-focused doctorate programs and that other titles now in existence-such as doctor of nursing-be phased out. The practice doctorate will be the terminal practice degree that prepares graduates in advanced practice nursing roles, such as NPs, clinical specialists, nurse anesthetists, and nurse midwives. Despite this recommendation, the Columbia University program has decided to retain the DrNP designation for their graduates because this title designation had been used over an 8-year planning period and approval process and was now in place. Most programs now operating as well as those in development have agreed to follow the AACN recommendation and to adopt the DNP title. There is a distinct difference between the practicefocused doctorate and the research-focused doctorate. The DNP, a practice-focused doctorate, is designed to broaden knowledge and clinical skills through preparation for advanced clinical work, leadership, and management via the application and use of research. The PhD 1, focused on research, generates new knowledge through the research process that informs and validates knowledge, interventions, and skills. Both types of doctoral programs can coexist in academic institutions as complements to each other because the curricula and foci are very different-practice versus research. More 1 When the PhD degree is mentioned, it includes the other research-intensive degree programs such as DNSc, DNS, and DSN. over, if a DNP graduate wishes to embark upon a research career, then he or she can apply for admission to the PhD program. The reverse is also true. Transitioning for Advanced Practice The transition process over the next 10 years will allow time to address the educational essentials for DNP programs. A concern has been raised by experienced MSN NPs who have, for many years, provided quality health care in a multitude of settings about the impact that this new degree will have on their practice. First, it is important to remember that the shift to the practice doctorate is an education-driven initiative. At this time, boards of nursing and certification agencies continue to require the MSN as a prerequisite to licensure or certification at the advanced level. Second, it is simply impractical to imagine that educational institutions are prepared to retroeducate more than 100,000 advanced NPs. One suggestion proposed by the AACN is that a mechanism be developed to provide MSN-prepared APNs with options for obtaining a DNP degree during a transition period. The essence of the recommendation is that previous graduate study and practice experience be recognized as components of acquiring the degree. For experienced APNs, the basis for advanced practice exists and course work will build on the knowledge and skills that provide a method to meet the objectives and core competencies for the DNP. Because this transition period will be time limited, it becomes imperative that APNs, who will be practicing beyond 2015, be aware of potential changes in advanced practice nursing practice regulation. Advanced practice nurses need to be aware of the opportunity to use practice and experience as components of acquiring this degree rather than enrolling in a complete program of study for the DNP or may choose options for grandfathering that may be offered. Alternatively, retirement and other life changes may obviate the degree for other MSNprepared nurses. Accreditation of Programs Accreditation of DNP programs will likely occur after developing and implementing the curriculum essentials for the degree. The AACN appointed a task force that was charged to identify competencies and curriculum essentials that would distinguish the DNP from the current MSN template. The NONPF has formed a national panel to identify outcome competencies for NP graduates of DNP programs. This effort is similar to what was done with the Essentials of Master's Education for Advanced Practice Nursing (AACN, 1996) and the Nurse Practitioner Primary Care Competencies in Specialty Areas: Adult, Family, Gerontological, Pediatric, & Women's Health (NONPF 1St AACN, 2002). At the present time, there is no national consensus on what the curriculum should look like and schools with DNP -

5 programs vary across their curricula. When the work of the DNP Essentials Task Force is completed, programs already in existence will have the opportunity to tailor their programs to meet the standards and competencies for accreditation. Issues As the DNP is discussed in various fora across the country, several issues have been raised. These issues relate to education, licensure, job market, and work environment. The discussion and debate are important because they allow stakeholders to respond, learn, react, and adapt to this change. Although feelings run high in this debate, all parties share the common concern that nursing education must be up to the challenge of producing the next generation of leaders and practitioners. Table 2. Doctor of Nursing Practice Programs Currently Accepting Students Program Location Case Western Reserve University Ohio Columbia New York Drexel University Pennsylvania Medical College of Georgia Georgia Rush University Illinois Tri-College University North Dakota University of Colorado at Colorado Denver and Health Sciences Center University of Kentucky Kentucky University of South Carolina South Carolina University of Tennessee Health Tennessee Science Center iii'!; Education Tofind the right program, students often check websites for advanced practice nursing programs. Marketing materials, national ranking, costs, and location are considered. Ultimately, students find a program that "fits." Students believe that the program they ultimately choose will prepare them to be competent APNs. The implicit assumption is that educators will know what students will need. Faculty must be up-to-date by practicing andlor monitoring current practice to prepare students to enter the health care arena, which is ever more complex and demanding (Sperhac &: Goodwin, 2003). Sometimes, facultyare reluctant to let go of content while at the same time adding additional content. Faculty are now faced with the increasing awareness that we are at the limits of what master's-level programs can accomplish. If educatorsare to maintain trust with their students to provide the education and skills necessary for practice, then educators must look into different models that allow the substitution of new knowledge for outdated information. The practice doctorate is a model that accommodates additional know ledge and skills needed for practice. Currently, there are 10 schools that are accepting students into DNP programs (Table 2) and approximately 40 programs either under consideration or in development (AACN, 2005). As described earlier, the 10M report and identificationof key competencies for health care providers had a significant impact on the AACN conceptualization of the practice doctorate. The 10M competencies are reflected in the recommendations put forth by theaacn (2004) in its position paper, which identified seven core areas of content (see Box 1) that should be included in practice doctorate programs. The thrust of these competencies is to educate nurses in an environof interdisciplinary cooperation with a deep ment understanding of the use of research and scientific methods and the tools to analyze and synthesize the data that emerge. These content areas are meant to be taken as guidelines rather than as a prescriptive formula for curriculum committees. Educational programs should be encouraged to design curricula in creative and innovative ways to meet the needs of their students, stakeholders, and faculty. Educational Resources A peripheral educational issue that needs to be addressed is how educational programs that do not, or are not authorized to, confer doctoral degrees will comply with the new educational mandate. Two organizations are working on possible solutions. The AACN Roadmap Task Force is committed to working with educators to seek creative solutions for these stakeholders. The NONPF Practice Doctorate Task Force has identified four curriculum models that describe multiple entry points culminating in the practice doctorate (Marion, O'Sullivan, Crabtree, Price,'&: Fontana, 2005). All four models specify options for postdoctoral education or PhD as alternatives. One of the strengths of this educational initiative is the appreciation that one size does not fit all programs. The outcome, the DNP, may be the same but many roads lead to it. In fact, valuable faculty resources may be conserved by limiting programs to what each institution is best qualified to offer and what the demographics will support. For example, an MSN program preparing NPs could continue its program and partner with doctoral degree granting institutions to complete the doctoral competencies. In this scenario, each educational institution is able to offer specific courses andlor residencies without further straining faculty resources. The DNP Versus the PhD The AACN recommendations clearly differentiate between the DNP and the research-focused PhD. Taken as a whole, the objectives for, and preparation of, practitioners under DNP programs differ from those under

6 12 PhD programs in several ways. A DNP-prepared practitioner develops the following: leadership skills for clinical practice (patient care, administration, clinical education); competencies for the highest level of clinical practice, integral to program planning; and skills needed to enhance clinical practice and affect health management systems. An issue that resonates with PhD programs is the potential for loss of PhD students because of drift to the practice doctorate. There is no datum to support this to date. Nevertheless, viability of any program should never rely solely on the fact that other options are not available. Both roles represent the knowledge and skills necessary to develop the profession with the appropriate set of tools to accomplish each mission. For DNPs, this means expertise in clinical practice and clinical teaching, leadership in health policy, and use as well as implementation of evidenced-based research practice for the benefit of patient populations. A PhD-prepared nurse is a generator of new knowledge, a teacher, a theory builder, and a historian who describes the past and portends the future of nursing. The differences in these roles do not suggest a hierarchy but a collaboration that uses the expertise and skills of both the DNP and the PhD to advance the art and the science of nursing. Legislation/Licensure Another critical element related to educational changes in nursing is the impact that legislation may have on programs and vice versa. Clinicians and educators frequently work together to advocate for legislation that enhances practice and the delivery of health care. Broadening the scope of practice may, at times, pose a threat to other health care providers, but it is a necessary process as a discipline grows and evolves. For example, in the very early years of NP education, pharmacology was integrated into didactic courses, but NP students were rarely enrolled in stand-alone pharmacology courses as in medical education. As practice evolved and NPs were engaged in diagnosing illnesses that required pharmaceutical interventions, it became apparent that prescriptive privileges would benefit NPs and facilitate the delivery of better health care. State by state, NPs sought prescriptive privileges that unfortunately resulted in a hodgepodge of rules and regulations that vary across states. Nevertheless, today in almost all states, NPs have some degree of prescriptive authority. State boards of nursing and federal programs currently recognize the MSN as the appropriate degree for entry into practice for NPs. A concern raised by practicing NPs is how boards of nursing would transition to the DNP as the recognized entry level of NP education and what effect it would have on NPs with MSN degrees. In anticipation of such questions, the AACN Roadmap Task Force will work with all relevant stakeholders to recommend viable solutions. At this time, there is I plan by regulatory bodies to require that all curren I practicing NPs obtain a practice doctorate; neither there any certification agency that requires the practi doctorate as an eligibility requirement. A Lesson From History In the early 1990s the MSN became the stand; educational preparation for NPs. Nurse practition who were not licensed or recognized as advanced l' were given the option of grandfathering to obtain maintain an advanced practice license. Many ven were used to announce the move to the MSN requ: ment and states provided a window of time for NP~ obtain the advanced practice license without complet the MSN. A similar process could be used as the D becomes the entry level into practice. Although some NPs will take advantage of the gra fathering option, this is generally only valid in respective states where the NPs are currently practic Should an NP move to a different state in which the be of nursing requires the DNP, then he or she would the held to the DNP standard. For this reason, it is impor for NPs to attend to announcements from board nursing and professional organizations. As discu previously, it is anticipated that many NPs will wis obtain the practice doctorate. As stated previously, Position Statement on the Practice Doctorate in NUl (AACN, 2004) specifically recommends a period MSN-prepared NPs to earn the DNP. with credit g to previous graduate work and clinical experience. Job Market Frequently raised concerns about the practice do ate are the issues of who will hire NPs with pra doctorate degrees and of whether the pay they re would be worth the additional education. In answ the first concern, employers are stakeholders as The intent of moving to the DNP as an entry le not an attempt to drive up salaries for APNs I recognition of the level of preparation that they receive to practice in today's and tomorrow's t care systems. During the transition time (i.e., urn 2015 deadline), employers may have the opti hiring a practitioner without a DNP degree; hoy generally, an employer hires for the skills and exf a potential employee can bring to a practice. 1 year 2015 nears, there may be fewer MSN-pre clinicians graduating while the number of graduates continues to grow. The question of salary is concerning to however, basing an argument on the worth of a can quickly become a slippery slope. Employers ally do not determine or raise salaries based solely degree a person holds. If it were so, then baccala: prepared nurses would always and everywhere more than associate degree or diploma nurses. V

7 I t1t:, IV~_' _. _. -., d S 's ir ~s LO 19 lp d he 19..rd be mt of sed to the ing for ven tor.tice eive.r to...ell. el is ut a nust ~alth 1the n of ever, -rtise ; the Jared DNP.ome; egree ~enerm the reatemake hat is expected is that clinicians prepared with a DNP will have the ability to demonstrate their worth based on the additional leadership, economic, and policy knowledge and skills that they will acquire in DNP programs. More importantly, they will know how to use that knowledge. Buppert (2005) suggests that tracking patient outcomes holds promise for two issues related to the economics of advanced practice nursing. The first is that providing evidence of improved patient outcomes, such as better control of hypertension or diabetes, is data that can be shared with employers to demonstrate that clinicians not only can generate revenue but also can improve the health of clients. The second is a marketing issue. With sufficient data, a practice could advertise positive patient outcomes, meaning less cost to consumers and better quality of life, which in turn generates more revenue with new clients. This clearly represents a shift in accountability. It is time that clinicians demonstrate to employers, legislators, and the public what their contribution and, by extension, their worth truly are. Recommendations Currently, organizations such as the AACN and the NONPF are working diligently through task forces to provide standards and guidelines for DNP curricula. It is tempting to design a plan of study that will provide all the content with all the proverbial bells and whistles to prepare clinicians for practice. However, as we have seen with the MSN programs, it quickly becomes a quagmire of credits, hours, and courses that seem never ending. The importance of guidelines that outline the essentials of the program of study cannot be overstressed. These guidelines should be detailed enough to provide criteria for quality programs without being so prescriptive that innovation and diversity are unable to flourish. In view of these thoughts, the following recommendations are offered: A solid liberal arts background is essential. The core and specialty competencies developed in MSN programs should be incorporated and refined to better meet the needs and objectives of the DNP program of study. As development of guidelines and standards moves forward, it remains vital that stakeholders continue to be involved in the process. A critical part of the acceptance and success of the DNP is the need for open dialogue in the mode of public fora. Professional meetings provide an opportunity to debate on and clarify pertinent issues. Open t lines of communication are fundamental in achieving consensus among faculty, APNs, regulatory bodies, and stakeholders. The program goal for the graduates of DNP programs should ultimately be to produce safe and competent practitioners. To achieve this goal, faculty will look into the guidelines that are currently in development and build on core and specialty content as well as Outcome competencies. Curriculum planners should be cognizant of the tendency that to equate more is better. Unwieldy plans of study that require inordina te time or number of credits for completion should be avoided. Programs will differ across the country, bu t it is logical that 3 to 4 years of postbaccalaureate education will be the norm. It is important to recognize that no matter what the level of terminal degree, graduates will emerge at various levels of mastery-from novice to advanceddepending on the knowledge and skills that they possessed when entering the program. Graduates of any professional degree program do not transition into the world of actual practice as experts. They rather use the knowledge and skills that they have acquired and apply them to their current practice situation. As experience is gained, so too are clinical judgment and expertise. Summary Advanced practice nurses across the country are engaging in dialogue and debate about the practice doctorate and what it implies for their practice and status. These conversations are good and necessary. Practice is never static and continues to evolve as new knowledge is generated and research identifies best practice. Standards of practice evolve from practitioners and researchers in the rich environment of the practice arena as the outcomes of evidenced-based research are tested and disseminated. Nursing has met head-on the challenges raised by the 10M report and has designed a program capable of meeting the needs of the 21st century health care system. The nursing practice doctorate is a product of vision and leadership. It would be reasonable to expect that as programs develop and mature, they will be subject to changes, additions., and deletions based on outcome criteria, standards, and competencies. In the future, new problems will arise in health care systems, as well as challenges in maintaining the cutting edge in advanced nursing education. The process to monitor and evaluate the programs of study is well established in the accreditation agencies of higher education. Collaboration between graduates of DNP programs and those of PhD programs will positively affect the health care system. Multiple voices have and are calling for nursing educators to support the practice doctorate. The National Research Council of the National Academies (2005) has identified the need for doctorally prepared practitioners in nonresearch clinical doctorate programs. The time has come for nursing to embrace the national agenda for advanced practice nursing, the practice doctorate. Acknowledgments We thank Dr. Kathleen Andreoli for her thoughtful review and assistance with the preparation of the manuscript.