DOCTORAL EDUCATION IN nursing is undergoing THE DEVELOPMENT OF PRACTICE SCHOLARSHIP IN DNP PROGRAMS: A PARADIGM SHIFT

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1 THE DEVELOPMENT OF PRACTICE SCHOLARSHIP IN DNP PROGRAMS: A PARADIGM SHIFT MARIE ANNETTE BROWN, PHD, ARNP, FNP-BC, FAAN, FAANP AND KATHERINE CRABTREE, PHD, FAAN Doctoral education in nursing is undergoing a paradigm shift. The doctor of nursing practice (DNP) degree was conceived to improve practice expertise and accelerate the translation of evidence into practice. The need for doctoral preparation that focuses on both expert practice and practice inquiry acknowledges the complexity of evidence-based practice. The DNP prepares graduates to practice at the most advanced level of nursing and to evaluate current practice approaches, to appraise evidence, and to use this knowledge to create clinical strategies that improve practice and health outcomes. DNP curricula need to evolve through shared best practices grounded in financial sustainability. Because of the evolutionary nature of new programs, there is a need for continuous rapid adjustment of the DNP curriculum. Ideas presented here have evolved with student, faculty, and agency input. Many elements of DNP curricula represent a shared world view of faculty across the county. However, consensus about the DNP project has not been reached and is urgently needed to promote acceptance of the DNP-prepared advanced practice registered nurse. The DNP project allows synthesis of the American Association of Colleges of Nursing DNP Essentials through real world translation of evidence into practice. This article proposes that DNP projects be defined as practice improvement partnerships between academia and community agencies. This win win collaboration can improve care while preparing the next generation of nurses for the demands of increasingly complex healthcare environments. (Index words: DNP; Practice doctorate; DNP project; DNP capstone; Practice inquiry; DNP curriculum; Practice change; Practice evaluation; Evaluation research; Doctor of nursing practice; Practice scholarship; Clinical scholarship; Clinical inquiry) J Prof Nurs 29: , Elsevier Inc. All rights reserved. DOCTORAL EDUCATION IN nursing is undergoing a paradigm shift. The advent of the doctor of nursing practice (DNP) degree occurred within the context of rapid adoption of evidence-based clinical practice in delivery systems. The American Association of Colleges of Nursing (AACN) DNP Essentials (American Association of Colleges of Nursing, 2006) have prompted national dialog about the appropriate type of education Professor, University of Washington School of Nursing, Seattle, WA. Professor and Associate Dean for Graduate Programs, University of Portland School of Nursing, MSC 153 Buckley Center, Portland, OR. Address correspondence to Dr. Brown: PhD, ARNP, FNP-BC, FAAN, FAANP, Professor, University of Washington School of Nursing, 1959 Pacific Street, Health Sciences Bld T-404, Box , Seattle, WA mabrown@uw.edu /13/$ - see front matter needed to prepare for practice at the most advanced level of nursing in concert with a new approach to the scholarship of practice and the scholarship of discovery (Boyer, 1990). In that vein, traditional research courses that have been viewed as essential for doctor of philosophy (PhD) students with a career trajectory as a nurse researcher are being examined as to their appropriateness for DNP students. These formative years in the development of the DNP are also occurring during financially vulnerable times for schools and for graduate students. The work of academia is to determine effective, financially sustainable ways to prepare advanced practice registered nurses (APRNs) to engage in expert practice and practice inquiry. Curricula are being reevaluated so that every credit, every course, and every dollar spent by doctoral students, as well as by schools, target the most highly relevant content Journal of Professional Nursing, Vol 29, No. 6 (November/December), 2013: pp Elsevier Inc. All rights reserved.

2 DEVELOPMENT OF PRACTICE SCHOLARSHIP IN DNP PROGRAMS 331 Debate and analysis of DNP program outcomes have shaped the skill set needed by APRNs to be successful at the new level of accountability for their practice. Many graduate students returning for a DNP are in part attracted by the potential to become a practitioner who can make a difference in health outcomes at both the individual and systems level. They understand that the fragmentation and failures of the current health care system demand practitioners who are change agents and caring providers. In choosing the DNP degree, they are committed to optimizing health care delivery rather than becoming a scientist who leads major research endeavors, which is an expected outcome of a PhD program. Expansion of doctoral education in both research and practice is essential to the profession. DNP curricula must provide opportunities for reflective practice, evidence appraisal, and translation, in addition to the pivotal mission of in-depth practice knowledge and skills. The momentum for expanded legal and practice autonomy of APRNs magnifies the need for educating practitioners at the most advanced level of nursing along with building new kinds of expertise in development, implementation, and evaluation processes that improve practice. Many elements of DNP curricula represent a shared world view of faculty across the county. However, consensus about the DNP project has not been reached and is urgently needed to promote acceptance of the DNP-prepared APRN. This article addresses issues surrounding a key component of the DNP curriculum, the DNP project. We argue for the adoption of a consistent approach across schools that would prepare students to conduct evidence-based practice change projects. A variety of factors contributing to diversity in DNP projects is noted, and recommendations for DNP curricula and educators are emphasized. DNP Preparation Addresses the Need for Evidence Translation Despite technological advances in communication technology, an unacceptable lag exists between the production of knowledge and the translation of that knowledge into health care that benefits patients. Furthermore, there is an exponentially increasing knowledge base available from research that needs to be translated into practice. The Agency for Healthcare Research and Quality (2011) Web site summarizes this longstanding dilemma about research: What has been learned in the research setting often is not implemented into daily clinical practice. It may take as long as one or two decades for original research to be put into routine clinical practice. Thus, the translation of research findings into sustainable improvements in clinical practice and patient outcomes remains a substantial obstacle to improving the quality of health care ( ahrq.gov/url retrieved on May 28, 2012). The persistence of the knowledge practice gap has prompted a profound change in the fundamental models used to prepare practice scholars. DNP preparation of practitioners is intended to deepen practice expertise and accelerate the translation process and address these gaps. The paradigm shift in thinking about the need for doctoral preparation for practice acknowledges the complexity of current practice and the urgent need for health care reform. The goal of the practice doctorate is to reduce the lag time between discovery of knowledge and its implementation in practice and enhance the clinician's local practice knowledge. Career scientists focus on theory testing, tool development, and generating new generalizable knowledge. In contrast, practitioners generate new knowledge from practice for local application. They evaluate current practice approaches, analyze what is known, and adapt/translate that knowledge into useable clinical strategies that improve practice and lead to better health outcomes. Practice knowledge derived from further evaluation of the strategies and the outcomes achieved is disseminated for peer review and validation of its usefulness to others. DNP programs are designed to develop expertise in nursing practice along with leadership for practice improvement, quality, and safety. The past decade of technological development, financial constraints, and advanced education in professional nursing degree programs has also contributed to the emphasis on evidencebased practice. These developments have accelerated and prompted what may be viewed as the new paradigm. A chorus of nurse educators calling for transformation of education for practice (Benner, Sutphen, Leonard, & May, 2009) is leading the way to a new understanding of scholarship. Practice Inquiry Is Foundational for the DNP In 2006, Magyary, Whitney, and Brown (2006) offered a conceptualization of and a language for practice inquiry to guide the development of core expectations about DNP education. Practice inquiry, they noted, is the ongoing, systematic investigation of questions about practice and therapeutics with the intent to evaluate and translate, as appropriate, all forms of best evidence into practice and to evaluate the influence on health care outcomes (p. 143). The National Organization of Nurse Practitioner Faculties' (2012) Core Competencies for Nurse Practitioners includes the language and focus of practice inquiry. These competencies address the AACN DNP Essentials and can guide curriculum development for all nurse practitioners regardless of the population they serve. Curricula in DNP programs have evolved through national dialog and shared best practices. Educators view the practice inquiry component as essential for the APRN practice role, which demands careful evidence appraisal and translation. DNP projects enable further development of expertise in practice inquiry through a practicum-type experience while deepening practice knowledge.

3 332 BROWN AND CRABTREE What Is the Goal of DNP Projects? DNP projects reflect university standards and faculty expectations for doctoral work. Most of the faculty teaching in DNP programs are themselves PhD prepared and are focused on research scholarship. Some may be new to advanced practice inquiry. Understandably, initial designs of DNP practice inquiry projects reflected familiar research curricula that prepared students to conduct research for doctoral dissertations or master's theses. New DNP-prepared faculty, feedback from DNP graduates and community agencies as well as faculty experience have enhanced understanding of practice inquiry and contributed to the evolution of current DNP project goals. The goal of DNP projects is to gain expertise in practice change and quality improvement. Individually or in concert with others, the projects often have implications for policy change at the individual, family, community, system, state, or national level. AACN DNP Essentials describe the final DNP project as follows: Doctoral education, whether practice or research, is distinguished by the completion of a specific project that demonstrates synthesis of the student s work and lays the groundwork for future scholarship. For practice doctorates, requiring a dissertation or other original research is contrary to the intent of the DNP. The DNP primarily involves mastery of an advanced specialty within nursing practice. Therefore, other methods must be used to distinguish the achievement of that mastery (p.20). Currently, considerable diversity exists in how the practice inquiry projects have been developed and implemented across DNP programs nationwide. In a review of approximately 130 Web sites of nursing programs offering a DNP, Brown (2011) noted that DNP program websites used 31 different names describing the scholarly project required in the AACN Essentials (see Table 1). Examples included practice inquiry project, DNP capstone project, scholarly inquiry project, translational research scholarly initiative, evidence-based project, advanced nursing project, research utilization project, and clinical research. Furthermore, these terms suggest significant differences in the forms that projects take and even in the essence of their goals. Divergent approaches range from professional portfolios to clinical dissertations to practice change projects that translate research into practice. This diversity in educational approaches to practice inquiry is confusing for those in the practice community who will be the early adopters in hiring DNP-prepared APRNs. Agreement on standards for the DNP project can further the acceptance of DNP programs and graduates. A Comparison of Inquiry in Curricula Designed for Research Versus Practice A chief characteristic of doctoral work is the ability of doctoral students to synthesize their knowledge in a culminating scholarly endeavor. Table 2 highlights research, inquiry, and evidence-based coursework commonly required in nursing doctoral programs and compares the foci of these two educational curricula. The PhD research-oriented dissertation is widely understood. However, the DNP project addresses increasing complexity of practice change in a clinical environment. For example a PhD dissertation includes an in-depth critical analysis to move forward knowledge development in the area. DNP projects typically include evidence appraisal that selects the most useful from both research and clinical literature for the population of patients being addressed. These kinds of evidence summaries answer questions about successful interventions that can be adapted to a different practice setting. Development of targeted evidence summaries and the ability to synthesize this knowledge for practice in an abbreviated and userfriendly format are essential skills for the DNP-prepared APRN functioning in a clinical environment. DNP Curricular Foundation for Evidence-Based Practice Change DNP coursework emphasizes organizational systems, change theory, diffusion of innovations, and cost analysis to prepare students for launching systematic change projects and evaluating their effectiveness and sustainability. Acquiring greater appreciation of the clinical environment, of the gatekeepers, decision-makers, and stakeholders, and of the organizational priorities and resources is essential to the DNP's leadership in practice improvement. An important but often overlooked curricular component is the development of expertise in reflective practice required to assess and implement evaluation of evidence and outcomes. Collaboration and communication in leading intraand interprofessional teams in sustainable practice change to improve health outcomes and to conserve Table 1. Examples of Types of DNP Projects U Research utilization project U Clinical research U Scholarly inquiry in U Capstone project nursing practice U Practice improvement project U DNP project U EB mentoring applied project U Dissertation U Comprehensive study U Doctoral thesis U Synthesis project U Clinical practice dissertation U Scholarly leadership project U EBP project U Advanced nursing project U Clinical inquiry project U Clinical immersion project U Practice project U Translational research project U Leadership project U System change project U Scholarly project U Advanced clinical project U DNP clinical project U Administrative project U Residency project U Translational research U Scholarly capstone project scholarly initiative U Portfolio U Clinical scholarship: Capstone U Clinical scholarship portfolio U Clinical scholarship project U Doctoral project U Practice inquiry project

4 DEVELOPMENT OF PRACTICE SCHOLARSHIP IN DNP PROGRAMS 333 Table 2. Comparison of Inquiry in PhD and DNP Curricula PhD Purpose: Generate new knowledge from theory testing, intervention trials, explication of scientific phenomena, and others, to expand body of science Proportion of curriculum devoted to methodology Curriculum prepares nurse scientists Curriculum emphasizes philosophy of science issues Content or method expert as primary mentor in the student's area of research Learns to analyze literature using in-depth theory and methods expertise DNP Purpose: Translate research into practice, generate new knowledge from practice, evaluate and change practice Proportion of the curriculum devoted to appraisal and translation of evidence for best practice Curriculum prepares practitioners Curriculum emphasizes strategies and approaches for evidence-based practice Faculty expertise in conceptualization of practice change, appraisal of evidence for practice and guidance of student to negative interprofessional collaboration and system change Learns to select the most relevant literature that focuses on translation to practice and appraise for application to practice resources are also paramount to successful practice change. Leadership, knowledge of quality-improvement strategies, and team-building skills are additional essential competencies. Expertise in both quality improvement and program evaluation prepare the DNP student for interprofessional collaboration. Accordingly, the DNP curriculum is infused with program evaluation, quality improvement, and benchmarking processes. The DNP student learns how to manage a project that involves multiple types of care providers. Contingency planning and conflict management are essential skills needed for practice change projects. The types of methods and analyses most commonly used to appraise evidence for practice change and to evaluate the outcomes of practice change are embedded in the DNP curriculum. Translating research across populations and clinical environments entails careful scrutiny by practitioners. The literature offers many evidence-based approaches to enhance care within hospital environments, whereas DNPs are needed to contribute innovative care models for primary care and ambulatory care environments and the transfer of care across settings. With a paradigm shift to practice inquiry, change, quality, improvement and program evaluation acquire greater emphasis in the DNP program. Successful translation of evidence to improve practice requires evaluation of health and system outcomes as well as the management of resources. Literature on quality improvement has grown exponentially over the past decade. Originating outside the health care industry with Deming (1982, 1986), quality improvement methods are now standard tools used to examine health care processes and outcomes. Quality measures are undertaken to inform and adjust processes to reach optimal outcomes. Quality improvement content includes benchmarking and use of statistical control in which thresholds are set to alert systems about changes in performance and outcomes that trigger early intervention. Trend analysis also guides early corrective action to maintain quality and reduce unnecessary costs. Knowledge about program evaluation in both ongoing and new service program evaluation is an important foundation for practice change projects. Formative and summative evaluations are included in the curriculum to guide activities and decisions about practice change. Success is measured by improvement in the quality of local practice, which leads to improvement in outcomes. Pragmatic considerations in DNP practice change projects may drive selection of intermediate outcomes for measurement rather than final outcomes to ensure timely student progression and graduation. The time available in the curriculum to devote to the DNP project completion is typically limited to 6 9 months. DNP students learn the necessity of demonstrating efficiency and effectiveness in order to warrant continued allocation of resources. Both quantitative and qualitative analyses are useful in evaluating practice change. Students apply quantitative analyses including descriptive statistics such as percentages, means, and critical threshold scores to identify characteristics of participants and outcomes. Students then learn to select the most relevant analytic strategy. Common analytic approaches in practice change projects may include correlation, chi-square analysis, independent and paired t tests, analysis of variance, and logistic and multiple regression. Clinical significance is a higher priority than primarily testing for statistically significant differences, which may not be reached because of the type or size of the sample. Six Sigma is a quantitative approach that provides a method of managing work processes to control unwanted variation. The multistep method is employed in manufacturing to reduce costly errors while improving outcomes and consumer satisfaction (Lucas, 2002; Taner, Sezen, & Antony, 2007). The aim is to take action when the defined limits of quality are exceeded by adjusting processes to restore optimal outcomes. Six Sigma sets limits for quality monitoring using boundaries based on the standard deviation for a normal population. The statistical method was also derived from manufacturing and is compatible with other quality improvement

5 334 BROWN AND CRABTREE techniques. Its application to health care was examined by Chassin as early as 1998 in response to the call for better health care and has been effective in reducing medication errors (Chassin, 1998; Esimai, 2005; Revere & Black, 2003). Equally important are qualitative data that describe processes and perceptions of participants captured during practice change projects. Interviews, observations, and focus groups probe the experience of patients, families, staff, and care providers to gain input from multiple perspectives. Students experience additional benefit in deepening their understanding and compassion for patient experiences. These qualitative approaches provide insights beyond quantitative results and help guide solutions. Qualitative approaches enrich the depth of understanding to inform decisions about effectiveness and sustainability of the practice change. Refinement of professional oral and written communication skills during DNP practice change projects is valuable and serves graduates in their career development. Helping future practitioners understand the need to improve their professional writing skills can enhance knowledge dissemination. Learning to write a brief, succinct proposal for an evidence-based practice change is different from writing a traditional thesis or dissertation proposal. The focused proposal is designed specifically for the type of collaborative decision making that occurs in practice settings. Table 3 illustrates one approach to instructions that may be useful to students in guiding a practice change proposal. The DNP project is the place in the curriculum where students come to the realization that practice expertise and knowledge alone are not sufficient. As DNP-prepared leaders, these APRNs begin to understand that they are equally responsible for other aspects of care for their patient population that address system constraints limiting quality, safety, and cost-effectiveness. Through the DNP project, students put their knowledge to work to solve practice problems and meet the needs of patient populations. Reflection on the practice improvement strategies and outcomes achieved are needed to further inform practice. Practice inquiry projects are expected to generate knowledge for practice from practice that may be of use to other providers who face similar problems. Approaches to Mentoring in DNP Projects PhD faculty mentors have expertise in the knowledge domain and/or methods that match the dissertation focus. The significant number of faculty hours invested in each PhD student's dissertation is considered an essential foundation for launching a career scientist. DNP student mentorship diverges from the PhD model. At this time, resources are not available to provide DNP students with this type of closely matched expertise or intensive 1:1 supervision. In contrast to the PhD individual supervisory model, DNP students will benefit from a different kind of mentoring that is more practice focused, team oriented and financially sustainable. Transition to curricula that focus on DNP students' involvement in real-world practice change projects highlights the critical role of the clinical agency, community setting, or system in providing the laboratory for synthesis of learning in deliberative change. DNP students work with a team of mentors, most of whom are staff or clinicians embedded in the site rather than a supervisory committee at an academic facility. The traditional model of a supervisory committee is replaced by group mentorship. Although some schools may maintain the academic mentor title of supervisory committee chair, they are likely to delegate the traditional duties to course faculty who are guiding a group of students who share a project focus, agency, or approach. Faculty will also continue to be vital in building community partnerships and guiding DNP projects. DNP Project Identification and Collaboration With Community Agencies Different approaches to identifying projects also may be needed depending on the students' level of experience as an APRN and educational level (e.g., postmaster's or postbachelor of science in nursing [BSN] education). Although most of the DNP programs currently focus on postmaster's students, it is essential to remain mindful of the needs and priorities of novice practitioners as we create the DNP. Because the number of post-bsn DNP students without nursing or advanced practice nursing experience grows, partnerships with knowledgeable clinicians become increasingly important. Lacking experience in the APRN role at entry, students are learning to translate research into advanced practice while in the program and need guidance in developing the project from both academic faculty and agency clinicians. In contrast with past research-oriented master's theses, DNP students are not required to identify a research content area or enter with a research idea in mind. Instead, they are encouraged to be open to formulate projects based on agency needs and view the project goal as learning the practice change process. Many students, particularly postbaccalaureate nurses entering DNP programs to become APRNs are not burdened with traditional research expectations. This can help reduce barriers for post master's DNP students who can be deterred from application by uncertainty or fear associated with identification and implementation of an original research project. Often, however, students' clinical interests and agencies' needs coincide. Faculty help to broker the matching process between students and the agency. Students develop skills in evidence appraisal and translation, which are applied to the DNP practice change project. Implementation of this practice change model is facilitated when faculty collaborate with agencies to elicit a list of needed improvement projects. It is essential, however, that the timing of the project implementation is compatible with the student's progression in the DNP program. Another model includes special opportunities where the postmaster's APRN student or student group in conversation with the agency identifies an appropriate DNP project

6 DEVELOPMENT OF PRACTICE SCHOLARSHIP IN DNP PROGRAMS 335 Table 3. Proposed Framework for Practice Change Proposals The DNP project proposal focuses on key aspects of a plan that can be used in practice settings for program planning/evaluation, reformulation of clinical services, and/or practice change activities. This overview will introduce ideas about the overall direction of the DNP practice change project, including the primary goal, specific aims, rationale, expected implementation plans, outcomes and deliverables. The format and components differ from a traditional research or research grant proposal. DNP projects reflect a collaborative effort with a community agency or health care facility, so many projects evolve over time as the agency and the student clarify the specifics of the project. In-depth details of specific implementation processes may not be known at the time students write their proposals. DNP proposals are intended to build expertise in writing the kind of documents that will be common in practice or agency settings. Write your proposal specifically for the director of the collaborating agency or the individual/s who would be determining whether you could move forward with this project. (Imagine you are writing this proposal for the person with the power to decide.) Refined professional writing skills are expected. The proposal is written in future tense using a formal writing style, which is professional, clear and appropriate for this agency/audience. Use of bulleted or numbered ideas is appropriate for this kind of proposal. Generally, the proposal is targeted for approximately five pages (exclusive of references/appendices) in order to build expertise in focused summaries used by community and practice settings. a) Title of the project, student's name Page numbers and running head with current date enhance readability b) Problem identification and significance The problem or issue to be addressed should be introduced and its significance summarized Use only the key pieces of data from the literature to highlight the dimensions of the problem (e.g., prevalence, negative health outcomes, cost) Subsection on definition of terms (if there are multiple abbreviations necessary) c) Focused brief evidence appraisal (including evidence table if appropriate)* Focused evidence appraisal of the most relevant and current scientific work that relates to the purpose of the project Consider what kind of data would be most convincing at your practice setting or agency (individual, community, or systems level) If possible, provide exemplars of current evidence from the literature on programs, interventions, and outcomes Minimize descriptive data unless higher levels of evidence are unavailable or if these data are the most pertinent for your project Highlight other agencies that have already tested and/or implemented this practice change or project if they exist Include any existing evidence from other similar projects that could support the idea that the project has the potential for this site If no evidence is available from similar projects, present the strongest evidence available about why this particular approach (i.e., to changing practice) is needed. *NOTE: This is a sample of key evidence that requires review of the most current literature but is not intended to be an exhaustive review. Its purpose is different from a research proposal. d) Purpose Goal of the project Example: Develop (or implement or evaluate) a practice improvement project that uses text message notification of pap smear results for women younger than age 30 with cervical dysplasia e) Implementation Components What? Who? Where? How? Timeline? Describe how the project will be implemented to the extent known. Describe the proposed sources of information and the kind of information that will be collected in order to carry out the project. The protection of human participants should be included if relevant. Generally, quality improvement projects initiated by an agency that are conducted in collaboration with a school of nursing student do not require a traditional human participant application. However, some kind of special form may be needed to comply with the university's human participants' committee process. f) Outcomes/End products/deliverables Describe what the agency will receive when the project is completed (written or oral presentation?). Clarify committee expectations about what they will view as the project materials for faculty review (same as agency deliverable or different?). Include plans for information dissemination g) References h) Focused evidence table and appendices (if appropriate)

7 336 BROWN AND CRABTREE topic. One example might be a postmaster's student who has specific project goals arising from his or her current practice and an insider's knowledge of agency needs. A second example might include a student who learned about a need for a policy change identified through other courses or clinical practica in the DNP program. Development of the topic and matching the DNP student with an agency can be a very time-intensive process for faculty. There is an urgent need to develop strategies that streamline this process. In one model, faculty would guide a group of students through their DNP project as an ongoing teaching assignment. These faculties might work with all students in a specific agency or work with the agency involving students sequentially until the project was complete. Regardless of the collaborative models used, these fieldwork experiences build marketable practice improvement skills among DNP students. The Win/Win of Practice Change Projects Collaborative practice change projects send a powerful message to the community about the enhanced practiceoriented expertise of APRN DNP graduates. DNP students experience the real-world process of implementing change and addressing unanticipated barriers while adapting timelines and approaches. They practice problem-solving skills as they learn to bridge practice and research. DNP projects also provide opportunities to partner with a vulnerable community to address the community's health care needs. DNP student projects strengthen university community partnerships, foster collaborative relationships, and assist resource-poor communities to address gaps in the quality of their health services. Students experience the value of making a difference for diverse communities beyond providing care to single individuals. Successful practice change projects are a win win for the community and the academic environment. DNP students become increasingly indispensable to the advanced practice community as highly desired team members who provide person power to help agencies address their needs. Particularly in this time of tight budgets with minimal financial resources for practice improvement initiatives, an enthusiastic and accountable team member can be the impetus for moving forward on a change initiative. DNP students working on practice change initiatives can help clarify a desired project's focus and assess, create, and implement the project. They can contribute to moving a pilot to full implementation or disseminate a project system-wide and foster sustainability of the change. Dissemination of DNP Projects Dissemination of the processes and/or results of the DNP project to clinical agencies and the profession are a component of the educational experience that help to solidify learning and demonstrate professional responsibility. An executive summary report to the collaborating agency is a key outcome of the practice change project and may be provided publicly or privately. Agencies may use these results in grant writing, accreditation of services, or even in marketing services to future consumers. Another mode for professional dissemination of practice change projects may be posters presented to the agency. The poster may allow the organization to highlight nursing's involvement in quality improvement efforts to agency colleagues, consumers, benefactors, and the public. Students may also share project findings through manuscripts for professional journals and presentations at professional meetings when appropriate. Searchable electronic academic databases such as university archives may include the DNP project report. Faculty Development Faculty development may be needed in methods of quality improvement, gap analysis, cost analysis, graphic data display, and trend analysis. APRN faculty may also desire opportunities to develop a broader expertise in practice change, population management, system change, and newer quality improvement methods such as Six Sigma. Faculty guiding DNP projects today need an appreciation of both the research and practice worlds to guide the student in bringing together the best of both worlds and translating them into practice. Faculty who have both research and clinical experience can mentor novice faculty. Bringing faculty together regularly to guide these projects as a group allows mentoring and role modeling by experienced faculty as new faculty learn to bridge both worlds. Mentoring faculty as they supervise DNP projects allows for collaboration and draws on the strengths of each faculty to provide excellent guidance to students while preparing additional faculty to lead practice improvement projects in the future. Conclusion Because of the evolutionary nature of new programs, there is a need for continuous rapid adjustment of the curriculum with revision based on student, faculty, and agency input. In summary, the DNP curriculum is not intended to prepare scientists for independent research. Rather the aim is to prepare for practice at the most advanced level of nursing in concert with expertise to translate evidence into practice and conduct practice inquiry to inform local practice. The art and science of translating evidence into practice change requires a different set of skills than typically provided in the PhD curriculum. The focus on practice improvement drives the curricular content in DNP programs. Practice improvement requires that students possess a command of practice problems and the ability to access and assess evidence-based literature for solutions to practice problems. Appraisal of research-based interventions requires knowledge of research methods. In order to translate essential evidence-based knowledge into practice, the DNP graduate needs additional preparation in and knowledge of change processes, organizational systems, and evaluation methods. Practice change also entails using many skills that flow from practice relationships, communication, and collegial collaboration. DNP practice change projects provide great promise for education of APRNs to integrate a new set of skills in

8 DEVELOPMENT OF PRACTICE SCHOLARSHIP IN DNP PROGRAMS 337 the work environment. Experience in leading practice change enhances the successful launch of the DNP's new career. When novices demonstrate competency in both practice and the conduct of practice change projects, the graduate of a BSN-to-DNP program becomes attractive to employers, even as a new graduate. Postmaster's DNP students who usually bring practice expertise into their DNP preparation will also find their practice change projects open doors at the project agency, whether a current or new place of employment. The graduates are poised to make important contributions to practice change throughout their career, building on the knowledge and skills acquired in the DNP program. Consistent approaches to practice inquiry in schools of nursing across the nation could strengthen the acceptance of the DNP-prepared APRN. We urge reexamination of DNP curricula to ensure that graduates are fulfilling the original promise of the DNP. The ability to practice at the most advanced level of nursing in concert with translation of research into practice is needed for the DNP nurse to meet the paramount need of society to close the practice gap. Implementation of health care reform along with scrutiny on the quality and cost of health care are timely mandates that improve the health of populations and lead to ongoing practice improvement. DNP practice change projects provide another opportunity for win win collaboration between academic nursing programs and our communities. References American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. Retrieved from, Agency for Healthcare Research and Quality. (2011). Translating Research into Practice (TRIP)-II Fact Sheet. Retrieved from, Benner, P., Sutphen, M., Leonard, V., & May, L. (2009). Educating nurses:acallforradicaltransformation. San Francisco: Jossey-Bass. Brown, M. A. (2011). Advancing practice through the DNP capstone. Presented at the American Association of Colleges of Nursing Doctoral Forum, San Diego, CA. Boyer, E. L. (1990). Scholarship reconsidered: Priorities of the professoriate. Princeton, NJ: Carnegie Foundation for the Advancement of Teaching. Chassin, M. R. (1998). Is health care ready for Six Sigma quality? The Milbank Quarterly, 76, Deming, W. E. (1982). Quality, productivity and competitive position. Cambridge, MA: Massachusetts Institute of Technology Center for Advanced Engineering Study. Deming, W. E. (1986). Out of the crisis. Cambridge, MA: Massachusetts Institute of Technology Center for Advanced Engineering Study. Esimai, G. (2005). Lean Six Sigma reduces medication errors. Quality Progress, 38, Lucas, J. M. (2002). The essential Six Sigma: How successful Six Sigma implementation can improve the bottom line. Quality Progress, 35, National Organization of Nurse Practitioner Faculties. (2012). Core competencies for nurse practitioners. Retrieved from: Magyary, D., Whitney, J., & Brown, M. A. (2006). Advancing practice inquiry: Research foundations doctor of nursing practice. Nursing Outlook, 54, Revere, L., & Black, K. (2003). Integrating Six Sigma with total quality management: A case example for measuring medication errors. Journal of Healthcare Management, 48, Taner, M. T., Sezen, B., & Antony, J. (2007). An overview of Six Sigma applications in the health care industry. International Journal of Health Care Quality Assurance, 20,