Foundations and Essentials for the Doctor of Nursing Practice

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Journal of Professional Nursing

journal homepage: www.elsevier.com/locate/jpnu

Doctor of nursing practice students' perceptions of professional change through the DNP program Eileen R. Giardinoa,⁎, Joanne V. Hickeyb

a Rush University, College of Nursing Adult Health & Gerontological Nursing, United States of America b University of Texas Health Science Center at Houston, Cizik School of Nursing Department of Research, United States of America

A R T I C L E I N F O

Keywords: Content analysis Thematic analysis DNP student DNP DNP program DNP student growth

A B S T R A C T

Background: This thematic analysis study examined how post master's Doctor of Nursing Practice (DNP) students described personal and professional growth in their views of self, healthcare, and clinical practice that evolved as a result of the curriculum and experiences in the DNP program. Purpose: The purpose of this thematic analysis was to describe and discuss perceptions of graduating post master's DNP students regarding personal and professional development that occurred during the DNP program to identify how DNP graduates saw themselves change and grow during the course of the DNP program. Method: A thematic analysis method was used to code, categorize, and summarize data from 42 reflection papers of post master's DNP students into a thematic framework based on the eight DNP Essentials which are the framework upon which DNP programs build their curriculum and design student experiences. The authors systematically analyzed the statements from each student paper and drew interpretation of the students' state- ments into themes that were congruent with the eight DNP Essentials and one stand-alone category. Results: Data analysis yielded 15 themes that were aligned within eight categories of the DNP Essentials and one stand-alone category. Conclusions: The eight DNP Essentials provided a framework for the themes which reflected professional growth attributed to the journey through the DNP program. A ninth category entitled Personal Advancements described students' perceptions of their personal and professional development. These dimensions are proposed in the new DNP Essentials currently in development. Increasing understanding of the DNP students' journey serves to inform DNP curriculum development and program experiences, and informs faculty of the influence they have on molding students into a more robust professional role.

Introduction

The Doctor of Nursing Practice (DNP) degree is the terminal prac- tice doctorate in nursing focused on preparing graduates to practice at the highest level of nursing practice to impact healthcare outcomes through organizational leadership, systems thinking, interprofessional collaboration, health policy, and direct patient care that contributes to the transformation of health care delivery. DNP nurses are change agents and innovators who create sustainable care and practice models to meet societal needs for equitable, affordable, and quality health care across the wellness to illness continuum. Throughout the DNP program, students change personally and professionally as a result of course content, professional experiences, and collegial and faculty interac- tions. The intersect of the student with a dynamic, adaptive, and challenging academic environment and health care system creates

ongoing growth opportunities from the start to completion of the DNP program While the post master DNP student comes to the DNP program as a master's prepared advanced practice nurse or administrator, the DNP program experiences expand the students' world to include ad- vanced knowledge from the analytical, biophysical, psychosocial, and organizational sciences, as well as health policy, ethics, scholarship, scientific writing, and executive leadership in the healthcare delivery system (American Association of Colleges of Nursing (AACN), 2006). All DNP educational experiences are focused on expanding a student's professional knowledge and expertise, beyond the curriculum content and outcomes of master's program education.

Although faculty interact with students throughout the DNP pro- gram and observe academic growth, students' self-perceptions re- garding professional growth at the end of the program are not clearly evident. In the last semester of an eight-semester part time DNP

https://doi.org/10.1016/j.profnurs.2020.08.012 Received 8 April 2020; Received in revised form 17 August 2020; Accepted 20 August 2020

⁎ Corresponding author. E-mail address: eileen_r_giardino@rush.edu (E.R. Giardino).

Journal of Professional Nursing 36 (2020) 595–603

Available online 26 August 2020 8755-7223/ © 2020 Elsevier Inc. All rights reserved.

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program, students completed an assignment that asked them to describe their professional growth and scholarly approach to health care and doctoral level practice and how their perceptions have changed since beginning the DNP program. The reflections of the 42 post master's DNP students described transformational changes in their personal and professional lives. The students' insights into their educational journey that emerged from the reflection papers were so rich that the faculty decided to examine the students' experiences from the perspective of how their experiences helped them achieve each of the DNP Essentials.

Background

Doctor of nursing practice degree

The DNP program is a practice focused doctorate designed to pre- pare nurses to work at the highest levels of professional practice in health care organizations. The DNP degree emerged due to societal needs for high level nursing leadership and practice to transform the United States health care system (Institute of Medicine (IOM), 2001). DNP curricula are innovative and were designed to include content on executive leadership, systems thinking, health policy, practice man- agement, informatics and technology, risk management, evaluation of evidence for evidence-based practice, appreciation of the increased complexity of patient care needs, complex health care delivery systems, patient safety and quality improvement initiatives, and interprofes- sional collaborative practice (American Association of Colleges of Nursing (AACN), 2019). This content is embedded in each of the 8 DNP essentials within the context of competencies that DNP graduates should achieve as a result of the doctoral program. There are a number of DNP essentials that address content that is based on clinical concepts.

All DNP students whether entering the program as a bachelor or master's prepared nurse, must achieve the same program competencies outlined in the DNP essentials. Because students enter the DNP program at different entry points (BSN or MSN), the DNP curricula is in- dividualized for candidates based on their education. As such, many masters prepared students who enter the DNP program with an MSN degree built on the AACN's Masters Essentials and have attained some curricular content that is foundational to further develop competencies reflected in the DNP essentials (American Association of Colleges of Nursing (AACN), 2006).

The curricula and learning experiences of DNP programs are based upon the Essentials of Doctoral Education for Advanced Nursing Practice (American Association of Colleges of Nursing (AACN), 2006) and are foundational competencies required of all DNP graduates regardless of specialty area. Just as a Doctor of Philosophy (PhD) or Master of Sci- ence in Nursing (MSN) degree is a degree title, the DNP degree does not designate a role or specialty area in which a graduate is prepared (American Association of Colleges of Nursing (AACN), 2006). Eight Essentials outline specific curricular elements and competencies that must be achieved in programs that confer the DNP degree and address foundational competencies that are core to all advanced nursing prac- tice roles. The overall DNP curricula are individualized for candidates based on their prior education and work experiences (American Association of Colleges of Nursing (AACN), 2006).

The growth in DNP programs has been stimulated by the IOM's The Future of Nursing: Leading Change, Advancing Health which re- commended that nurses should work at the top of their license while inspiring nurse leaders to embrace the fact that they have the back- ground, skills and abilities to reform the healthcare system (IOM, 2011). The current proliferation of DNP programs as of 2020 shows there are 348 schools that offer DNP degrees in the United States (U. S.), with many new DNP programs in the planning stages. Universities in all 50 states plus the District of Columbia offer the DNP curricula (American Association of Colleges of Nursing (AACN), 2019). The number of DNP graduates has increased significantly over a 15-year

period as evidenced by a 2017 to 2018 increase from 6090 to 7039 (American Association of Colleges of Nursing (AACN), 2019; Bowie et al., 2019; Demonbreun, 2016).

Focus of the DNP and PhD prepared nurse

The focus of the PhD degree in nursing is on research methodology, scientific content, and how to implement the science of discovery based on implementing original research and completing research initiatives (Trautman et al., 2018); The PhD student learns how to lead research initiatives, develop theories that explain phenomena, and develop and testing methods of inquiry that generate knowledge (American Association of Colleges of Nursing (AACN), 2006) and address phe- nomenon that informs translational research and the science of im- plementation science (Williams, 2011).

DNP programs focus on the scholarship of application, integration and clinical practice to enable graduates to implement evidence from research into clinical practice. DNP nurses are practice experts, con- ducting assessments driven by data, applying research concepts to better implement evidence into practice, evaluating clinical outcomes, and determine strategies to improve the safety and quality of healthcare processes (Trautman et al., 2018). The DNP program prepares nurses to address complex patient and organizational issues in healthcare sys- tems.

The emphasis of the research focused PhD degree is knowledge development and includes content on theory development, research design and methodology, and statistical analysis all directed at the scholarship of discovery and generation of new knowledge, while the focus of the DNP degree is on the scholarship of application and in- tegration through the use of research, organizational leadership, prac- tice and quality improvement, innovation in care delivery models, evaluating and improving healthcare outcomes, and informing health policy (Marion et al., 2003). Nurses who pursue a doctoral degree in nursing consider the benefits and the differences between what the PhD program verses the DNP program offers. Both PhD and DNP nurses are needed to meet the crucial need for improved healthcare (Rodriguez, 2016).

Professional Identity formation

Identity formation is a developmental adaptive process that occurs at both at an individual and collective level. The individual level in- volves a psychological development while the collective level en- compasses a socialization process into professional roles and partici- pation in the work culture and environment of the community (Jarvis- Selinger et al., 2012). A professional identify develops over a lifetime of experiences from personal experiences, educational opportunities, and professional experiences (Johnson et al., 2012).

A nurse goes through the process of professional identity formation with each level of education, from the basic nursing program to achieve registered nurse (RN) licensure through the masters and doctoral pro- grams. The processes of education help to develop or form one's value system and perception of self in which professional roles and personal attributes express themselves in specific pursuits and behaviors within a community (Cruess et al., 2014). For a nurse, educational experiences are a key factor in developing one's professional identity because the knowledge and skills gained in the professional nursing arena are dif- ferent from those gained in the non-nursing world (Johnson et al., 2012). Along with formal education, each new position provides new skills and experiences that reshape and reform the nurse's professional identity. Each level of educational experiences, from bachelor to doc- toral program, is vital in the building of ones' personal identity. The DNP program plays an active part in the formation of DNP students' professional identity development (Ware, 2008). Nursing faculty and clinical preceptors in DNP programs significantly influence the

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development of professional identity. Therefore, it is important that they understand both the positive and negative effects they can have on the development of DNP students (Andrew et al., 2009).

Professional socialization and role development

The professional socialization process is a fusing of professional training and experiences with a sense of self (Hafferty, 2009) and differs from the professional education process. By comparison, socialization involves the merging of knowledge and skills with a sense of what occurs within an individual as a result of a complex interaction of personal experiences, ones' reflection on professional experiences, and an internalization of social interactions that come together to socialize a person into a profession (Hafferty, 2009). Professional socialization is a process by which an individual acquires the skills, attitudes, values, norms, and knowledge necessary to competently perform their profes- sional role (Cruess et al., 2014). At the first level of nursing education, either in a baccalaureate or associates degree program, an individual experiences initial socialization into the nursing profession where the clinical care aspects of nursing care as well as values, roles, and societal expectations are learned.

Professional role development involves the internalization of clin- ical and educational experiences that alter self-identity, ethical com- portment (Benner et al., 2010), development and integration of pro- fessional role components, and resocialization in the work environment (Brykczynski, 2014). Nicol et al. (1996) skill acquisition model ad- dressed how skills and role perspectives are a function of the nurse's familiarity with particular situations in combination with educational experience. In doctoral education, nurses continue role development by incorporating previous clinical and educational with dynamic experi- ences of the doctoral program (Brykczynski, 2014). Graduate nursing education is generally focused on specialization preparation which in- cludes nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist (CRNA), nurse midwife, or administrative positions. Masters and doctoral nursing education open the nurse to further in- ternalize the different level of health care, and a socialization process that incorporates different values and norms of the nursing profession at a higher level of responsibility and accountability (Cruess et al., 2014; Hafferty, 2009).

Purpose

The purpose of this thematic analysis was to describe perceptions of graduating post master's DNP students regarding personal and profes- sional development that occurred during the DNP program to identify how DNP graduates saw themselves change and grow during the course of the DNP program. Understanding how the doctoral program changed the lives of those who go through the program serves to better inform DNP curricula, program experiences, and student–clinician relation- ships.

Method

Sample

The sample for the thematic analysis was 42 post master's DNP students enrolled in a seminar course in the last semester of the three- year eight semester DNP program. All of the students enrolled in DNP program had completed a masters in nursing at an accredited MSN program. The DNP program enrollment options offered at the School of Nursing included: nurse executive, 47.6%, nurse practitioner, 28.6%, informatics, 16.6%, and CRNA, 7.1%. All but two students were em- ployed in full time nursing positions. Many students were in leadership positions in clinical facilities and had 8 to32 years of escalating work experience before enrolling in the DNP program. The demographics of the student sample are: female, 93%, male, 7%; Caucasian, 45.2%,

African-American, 26.1%; Hispanic, 19%; multiracial, 7%, and Asian, 2%. The mean student age was 44.6 years.

Context

The context for the thematic analysis was a school of nursing in a large southwestern city that established a post master's DNP program in 2006. The students were in their third year of an 8-semester hybrid DNP program and formed a cohesive cohort by completing courses together in monthly face-to-face class meetings and an on-line educational platform. Throughout the eight semesters of the DNP program, students came to campus for two full days of classroom teaching each month of each semester The post master's DNP program enrolled post-bacca- laureate prepared nurses who were advanced practice registered nurses (clinical nurse specialist, nurse practitioners or certified registered nurse anesthetists (CRNAs), masters of business administration (MBA)/ masters of public health (MPH), or master's prepared nurses with lea- dership experience. DNP students matriculated into one of four dif- ferent options focused on nurse practitioner/CNS, nurse executive, certified registered nurse anesthetist, or nurse informatics. The data for the content analysis was collected in 2019.

At the time the students wrote the reflection papers for the course assignment, the authors gave no thought to using the papers for a thematic analysis. The idea to analyze the course assignment reflection papers emerged after the authors saw the rich statements about how the DNP program experiences, faculty, and preceptors shaped personal and professional development. Student reflections described how students understood the DNP Essentials and attained DNP competencies.

Methodology

A thematic analysis is the methodology selected to describe DNP students' self-reflections upon completing the DNP post masters' pro- gram. Thematic analysis or thematic content analysis is an independent qualitative descriptive approach to identify, analyze and report themes or patterns or within data (Braun and Clarke, 2006; Vaismoradi et al., 2013). The aim of thematic analysis is to examine the self-reflective narratives by separating text within the reflection papers into smaller units of content and analyzing those statements to identify themes that emerge from student' statements and descriptions of their DNP program experiences (Sparkes, 2005). In thematic analysis, a theme's importance is determined by whether the theme captures something important in the overall experience, and not on the frequency of a theme's occur- rence in the text (Braun and Clarke, 2006; Vaismoradi et al., 2013).

The authors used the thematic analysis method to code, categorize, and summarize data into emerging themes based on student comments, descriptions, and statements in the reflection papers. The authors sys- tematically analyzed the statements from each student paper and drew interpretation of the students' statements into themes that were con- gruent with the DNP essential categories (Bengtsson, 2016; Hsieh and Shannon, 2005).

Tool

The instructions for the reflection paper assignment were the basis for the content of the assignment. Table 1 shows the instructions for the reflective paper assignment.

Procedure

The review by the Institutional Review Board (IRB) of the university stated that the thematic content analysis did not require IRB review (S. Romo, personal communication, January 7, 2020). The data for the thematic analysis were obtained from student papers written for an assignment for an end of DNP program seminar course. Students com- pleted the reflection paper assignment according to assignment

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instructions outlined in the course syllabus and on the online course platform (see Table 1). Each student submitted their individual paper to the online course platform for grading, according to the criteria stated in the syllabus. After the completion of the course, and/graduation from the DNP program, the course faculty decided to complete a thematic analysis of student reflections on how the DNP program experiences related to the DNP Essentials and contributed to professional develop- ment and competency achievement.

At the time the students were writing their reflection papers, the authors gave no thought to using the papers for a thematic analysis. The intent to do a thematic analysis came after the authors read the course assignments and saw rich statements regarding how the DNP program and faculty and clinical preceptor experiences shaped personal and professional development, and how student reflections connected their professional growth to the DNP Essentials.

The procedure used to analyze the data in the student papers was adapted from processes of thematic data analysis as described by Braun and Clarke (2006) and Vaismoradi et al. (2013) see Table 2.

Ethical considerations

All student information or identifying data from the students' papers was de-identified.

Data analysis

The two authors analyzed each of the 42-student papers

independently and then analyzed the independently gathered data to- gether. The authors designed a data extraction/analysis tool, or coding form, to extract exemplar statements from the papers that reflected students' professional learning, changes in knowledge and attitudes, and how students applied principles and concepts learned from the DNP curriculum. Statements extracted from each reflection paper were in- cluded on the authors individual coding sheet.

The process of discussion, data analysis, and coding of the phrases was the basis of the emergence and refinement of major themes. Emerging themes that did not mesh with the eight DNP Essentials were placed into a ninth stand-alone category entitled Personal Advancements.

Findings

Data analysis yielded 15 themes that were aligned with the eight DNP Essentials and one stand-alone category. The eight DNP Essentials provided a framework for the themes which reflected professional growth attributed to the journey through the DNP program. A ninth category entitled Personal Advancements described students' percep- tion of their personal and professional development. Student statements were organized into themes, and the themes categorized into one of the eight DNP Essentials. The themes that emerged from the student papers were reflective of The Essentials of Doctoral Education for Advanced Nursing Practice (American Association of Colleges of Nursing (AACN), 2006) and provided examples of achievement of these Essentials. Table 3 shows themes according to the eight DNP Essential categories plus an additional category of content that did not fit a DNP Essentials category.

DNP essential I. Scientific underpinnings for practice

The scientific underpinnings for practice were implied in all of the statements in the students' papers. The DNP program curriculum helped students learn the scientific underpinnings to support nursing practice and the science underlying practice in all aspects of health care de- livery. Students experienced a refocus in their practice from that of doing tasks to recognizing and utilizing the broad scientific under- pinnings for practice and care delivery.

DNP Essential II. Organizational and systems leadership for quality improvement and systems thinking

DNP Essential II encompasses a broad range of DNP curriculum content from leadership in organizations and systems to quality im- provement and becoming a systems thinker (American Association of Colleges of Nursing (AACN), 2006). The three major themes that emerged were 1) leadership development, 2) understanding profes- sional responsibilities, and 3) development of systems thinking.

Leadership development DNP students identified growth in leadership skills and perception

of having become a better leader in their organizations as a result of the DNP program experiences. “I have a greater understanding of my role as a leader and strategic systems thinker”… “I have a deeper under- standing of what it takes to be a good leader and to promote change, growth, and positive outcomes”. Program experiences helped students understand how to create change in a healthcare system. Both experi- ences and knowledge of change processes empowered and motivated students to determine needed system changes and implement them. One student said, “This program has empowered, motivated, and in- spired me to develop interventions that can change practice and sustain those changes”.

Understanding professional responsibilities Students identified a new understanding of their professional role

Table 1 Instructions for the reflection paper assignment.

Based on your fellowship objectives and the DNP competencies that you choose to expand during your fellowship, write a 5 to 6-page scholarly paper that includes the following elements:

• Introduction that describes why you selected particular DNP Essentials and list objectives for your fellowship experience related to each DNP Essential. • Describe how the selected DNP Essential contributes to your professional development. • Describe how your fellowship experience increased your competency for each selected DNP Essential. • Discuss new insights that you developed as a result of your fellowship experience including leadership and innovation related to the DNP competencies. Describe how you will incorporate these new competencies into your practice

Table 2 Steps of the thematic data analysis.

Step Process

1 Familiarization with data Each author independently read each paper, Transcribed data, read and reread the data, noted initial ideas from statements

2 Generated initial codes from the statements Coded interesting aspects of the data across entire data set

3 Developed themes from the coded data Collating codes into potential themes, gathering all data relevant to each potential theme.

4 Authors met together on a regular basis to discuss codes, themes, and meaning of the themes in relation to DNP Essentials

5 Reviewed themes in relation to DNP Essentials categories Checked if the themes related to the coded extracts and the entire data set, generating a thematic map

6 Defined and named themes Refined the specifics of each theme and the story that the analysis told

7 Produced the report The final opportunity for analysis. Selection of, compelling extract examples, relating back of the analysis to the research question and literature, producing a report of the analysis

Source: Braun and Clarke (2006) and Vaismoradi et al. (2013).

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and commitment to the professional responsibility and accountability that comes with a broader vision regarding ones' expertise in under- standing health care issues. One student stated that “while the nursing profession has always been important to me, I didn't understand my responsibility or ability to contribute. DNP preparation gave [me] greater confidence in advocating for the DNP role, health policy, and patient care issues”. Comments described an understanding of what the DNP brings to the professional arena and developing a strong com- mitment to advancing the work of their profession. A student described a strengthening of their voice and ability to “sit at any table and speak up for my patients, families, and staff” as a result of their DNP program experiences. The DNP program “provided me with confidence and in- sight into what is possible for me when I graduate… My confidence is certainly enhanced”. Confidence in self and professional ability emerged in their role as a nurse leader.

Development of systems thinking Students broadened their understanding of systems level thinking

by expanding thinking skills to improve problem solving and affect change. They described an ability to see beyond the immediate situa- tion and “look at organizational goals and decisions with a more in depth understanding of why and how that situation affects the larger system”. “The DNP program changed my perspectives to look at the health care system in a broader way… I can use systems thinking to evaluate and solve the multiple complex issues that hinder care delivery to patients”. Student descriptions of “a broadened view” and “thinking at a higher level” suggests a transformation of their professional world that enabled them to be more effective in problem solving and affecting outcomes. “Prior to my enrollment, I was involved from an organiza- tional level in initiatives which impacted nursing; however, I find myself to be more system level thinking going beyond the boundaries of the organization and making key decisions that positively affect the system level”.

DNP Essential III. Clinical scholarship and analytical methods for evidence- based practice

DNP graduates develop competence in knowledge application ac- tivities to provide leadership for evidence-based practice. The DNP graduate learns to translate science to practice and generate evidence through their practice to guide initiatives that improve outcomes of care (American Association of Colleges of Nursing (AACN), 2006). Three major themes emerged: translation of science, evidence-based practice (EBP) and, importance of quality improvement. Although DNP

Essential II uses the term quality improvement in its title (Organiza- tional and Systems Leadership for Quality Improvement and Systems Thinking), it is in DNP Essential III that the design, implementation and evaluation of quality improvement initiatives are described as a com- ponent of what the DNP program prepares the graduate to achieve (American Association of Colleges of Nursing (AACN), 2006).

Importance of translation of science and evidence based practice Students described how their ability to appraise evidence and

translate evidence to a clinical practice perspective enhanced their credibility with colleagues in their leadership roles. “I enjoy sharing expertise and translating research findings into practice to help improve health care quality and patient outcomes”… “Physicians and nursing staff I encounter expect this critical appraisal of research and quality improvement initiatives. [These principles] allow me to sit at the table and effectively discuss current recommendations and possible changes in our evidence-based model of care”. The DNP program provided structure to help change approaches to practice and understand the importance of a scholarly approach to situations and reviewing scho- larly literature to understand varied viewpoints and make wise deci- sions. One student stated that the “program taught me the importance of a thoughtful, scholarly approach. My “type A” personality tends to rush in and go directly to a solution. After my DNP journey, I stop to involve others, fully evaluate the situation, and move forward with purpose”.

Students developed a better understanding of EBP processes and the importance of using evidence from research and research-based litera- ture to support issues. “[I] regularly ask if a particular practice is really best practice [and] look into the literature to see what is out there about issues we are discussing”. Students indicated that they use relevant information to make organizational decisions and translate evidence into practice that was necessary to affect change on a local, national and global levels. “I now regularly incorporate the importance and emphasis on literature into my practice, and it is an expectation of the teams that report to me to review the literature related to projects they are working on”.

The DNP program improved their ability to understand how to appraise research findings to determine best evidence for practice. One student described an “increased confidence differentiating between high- and low-quality literature” and an increased ability to use scho- larly support for making clinical decisions. Another student described their ability to share evidence-based findings with colleagues in inter- professional situations, rather than supporting interventions from one's own perspective. “I feel more comfortable reading the available

Table 3 Themes associated with the DNP essential categories.

Categories Themes in category

DNP Essential I: Scientific Underpinnings for Practice Essential I implied in all theme categories and student comments.

DNP Essential II: Organizational and Systems Leadership for Quality Improvement Leadership development. Professional responsibilities. Systems thinking.

DNP Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice Translation of science and evidence-based practice. Quality Improvement.

DNP Essential IV: Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care

Value of informatics Power and use of data

DNP Essential V: Health Care Policy for Advocacy in Health Care Responsibility for political activism/advocacy DNP Essential VI: Inter-Professional Collaboration for Improving Patient and Population Health Outcomes Improved ability as an interdisciplinary collaborator and

leader. DNP Essential VII: Clinical Prevention and Population Health for Improving the Nation's Health Improved perspective on national and global health.

Application of population health principles. DNP Essential VIII: Advanced Nursing Practice Importance of innovation.

Transformative experience. Personal and Professional Advancements from the DNP Program The DNP Journey.

Pre-program perceptions.

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literature and analyzing the weaknesses and strengths to see if the evidence is applicable to my practice”.

Importance of quality improvement Students came to understand and appreciate quality improvement

skills needed to develop and implement a quality initiative, as well as the importance of improving quality and safety outcomes in an in- stitution. “I now see the tremendous depth of knowledge and skill [needed for] quality improvement to directly impact patient care”. “The DNP program curriculum helped me to plan, execute, and evaluate a quality improvement initiative in my organization that yielded very favorable results”. Students identified how “learning the complexities involved in a successful process improvement allowed me to fully un- derstand that nursing must be included in all conversations around health care delivery”. Understanding underlying principles led to suc- cess in their professional roles and made DNP graduates better able to make positive changes in patient care and healthcare systems. “I thought I knew the basics of how to conduct a quality initiative, but the DNP program made me realize there was a lot more I needed to learn. Now I understand how to appropriately conduct a quality improvement project”.

DNP Essential IV. Information systems/technology and patient care technology for the improvement and transformation of health care

Essential IV addresses DNP proficiency in the use of information systems/technology resources to support clinical practices, adminis- trative practices, and improvement initiatives. A curriculum focus is on the DNP graduate being prepared to understand information systems, health care technology, and ethical and legal issues. The two themes that emerged were: Importance of information technology and the use and power of data.

Importance of information technology Students described a new appreciation for what informatics and

information technology brings to the health care arena. They described how the understanding of skills needed for high level informatics in clinical care and the value of using information systems and technology to improve clinical care helped to leverage technology and information systems to evaluate and improve care. One student noted, “learned that nursing informatics is an essential component in the application of evidence-based practice” while another student reported being “un- iquely positioned to respond to these new innovations [and able to] serve as a bridge and a conduit between other clinicians and the in- formatics team”. Students gained a better ability to bridge clinical needs with information technology.

Use and power of data Students identified how the DNP program content and experiences

helped them understand the use and power of data to explain research findings and outcome data to make clinical decisions. One student said that “I learned how to retrieve statistical data from the stroke care registry and how these data are used to make clinical decisions to im- prove stroke care”. Students identified the necessity of understanding data-based reports and the importance of knowledgeable data dis- semination. “My thinking and expectations have changed in the way that information should be presented to certain audiences… I now ex- pect more from direct reports as well as my own leaders”.

DNP Essential V. Health care policy for advocacy in health care

The DNP program prepares graduates to understand, influence, and implement health care policies that affect institutional, local and na- tional issues. Essential V describes the DNP graduate as an advocate for health care policy who can address social justice and health care

equality at the individual and population levels (American Association of Colleges of Nursing (AACN), 2006). The major theme that emerged was the responsibility for political activism/advocacy to influencing health policy

Responsibility for political activism/advocacy Students described a new understanding of the need for nurses to be

active in the political arena to influence health policy. “My confidence has grown in the arena of political activism”. I saw how “crucial [it is to] function competently in the political sectors”. One student described how “The DNP program sparked an ideology that nursing professionals as a whole need to unify and engage in health policies that affect nursing and the community” to create change [in] health care at local to national levels.

The knowledge gained through DNP course work gave students an awareness of their ability to speak to policy issues at state and national levels. A student stated that “DNP prepared nurses are well-equipped to lead and engage in legislative advocacy [and] have the knowledge and skill to actively engage in the legislative advocacy process”. DNP stu- dents found voice as a health care advocate to see the influence they could have in all areas of health care. “I will have the courage and confidence to be more involved in implementing changes to nurse po- licies”. These policies are essential to setting the scope of practice for advanced practice registered nurses (APRNs). Comments showed that program experiences in health policy activities opened minds to un- derstand that the DNP graduate could and should advocate for health policy issues. “It is important for nursing to have a voice, and for re- presentatives to hear all sides, especially the nurses' perspective”.

DNP essential VI. Interprofessional collaboration for improving patient and population health outcomes

Essential VI addresses the communication and collaborative skills that the DNP graduate should have to be effective in all areas of health care practice. The graduate should be prepared as a leader of in- traprofessional and interprofessional teams to create change at all levels of healthcare delivery systems. One major theme emerged: improved ability as an interdisciplinary collaborator.

Improved ability as an interdisciplinary collaborator Students described the importance of an interdisciplinary approach

to mutual goal setting and communications. One student described that “I gained insight on the importance of an interdisciplinary approach, and breaking silos between healthcare settings and disciplines, which allows for more effective collaboration to have a successful population healthcare delivery system”.

DNP program activities shaped skills in facilitating collaborative activities and gaining confidence in leading interprofessional teams. One student described that “experiences [with] interprofessional team collaboration provided me with the confidence to participate and lead interprofessional teams. I learned the challenges and obstacles that one can face when working with various entities”. Students identified how being an effective interdisciplinary collaborator helped in becoming a leader, consultant, advocate and policy maker.

DNP Essential VII. Clinical prevention and population health for improving the nation's health

The focus of Essential VII is on learning about population health and clinical prevention issues. The graduate should develop in their un- derstanding of the relationship between psychosocial dimensions and issues of cultural diversity in improving the health of populations and preventing disease. It is important for nursing leaders to understand how to apply prevention and population health concepts to all aspects of health care (American Association of Colleges of Nursing (AACN),

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2006). Equally important, is the understanding of the determinants of health and wellness. Two themes emerged: improved perspective on global health and application of population health principles.

Improved perspective on global health Student comments showed an understanding of the need to create

healthy populations through prevention and wellness. DNP program experiences helped them better understand how global health issues affect communities. One student stated that “the program pushed me to have an impact on nursing and global problems” and now “views health care with global goggles”. Another student comment stated that “de- terminants of health are common themes that play out as the drivers of health care outcomes” and “the global health perspective fostered my understanding of health care quality improvement, and efforts made towards improving health care globally”. Students identified the im- portance of understanding global health perspectives in improving health care, “It is easy to view health care in the developing world as something affecting others, but this healthcare burden is carried by developed countries” and awareness that “situations can be totally different in developing nations compared to the USA”.

Application of population health principles The concept of population health is generally new to nurses despite

education at the master's level. “Prior to the program, I never con- sidered the concept of population health… I was not concerned with the unmet needs of the population and could not articulate the impact that nursing would have on the country's ability to meet that unmet need”. The DNP curriculum opened eyes to Population health principles and led students to a greater understanding of the connection between po- pulation health and improved health outcomes, “population health shifted my view of understanding patient care across the continuum, and the need to not only treat the patient as an individual, but to focus on the health and wellbeing of the population”. Through insight gained from population health issues, students described a new desire to apply population health principles to all aspects of clinical care, “I am able to develop a roadmap on how to improve population health by linking theory, practice, and policy through evidence-based practice that can impact the health of individuals, the nation, and the world”.

DNP Essential VIII. Advanced nursing practice

Essential VIII addresses foundational practice competencies of clinical judgment, systems thinking, and accountability in the larger domain of nursing that cut across the advanced practice specialties in order to design, deliver, and evaluate evidence-based care. The DNP graduate has the skills to assess health and illness parameters, address therapeutic interventions, and guide nurses to achieve excellence in nursing practice. Students learn how to be an innovative leader who practices at the highest level of nursing within the health care system. Two major themes emerged for Essential VIII: importance of innova- tion, and transformational experience.

Importance of innovation Students described how the DNP program opened them to an un-

derstanding of the intersect between change and innovation in the area of care delivery and health care practices. A student described that “I understand why innovation is so important, as health care executive leaders try and keep pace with the ever-changing health care environ- ment. The DNP program has helped me to connect the dots, and I can now confidently contribute to those discussions in a meaningful way”. Being aware of the concept and implications of innovation is another way of contributing to interprofessional discussions and being relevant in an ever-changing health care system. Another student stated, “I find myself being innovative in problem-solving and looking for ways to create positive change while keeping patient-centered care delivery as a core concept of my health care practice”.

Transformative experiences Students identified that the transformative learning opportunities in

the DNP program expanded all aspects of their professional knowledge. One student credited the people who inspired her transformation, “[the] amazing people, professors, colleagues, and healthcare profes- sionals from many facilities [have] inspired me to see a different per- spective about nursing practice, adding significant depth to my own practice”. The journey that the DNP program inspired “prepared me to be in a position where I can confidently speak up and discuss issues to impact results, initiate change [and] work in a collaborative setting continually building on my transformational leadership style”. Another student stated that, “my level of thinking has been elevated and it shows in my encounters with others, my writing, and in my self-con- fidence”. By the end of the program, students started to see a clarity in understanding the impact of DNP education in practice as an innovator and leader in nursing. “I am confidently prepared to lead health care innovation and influence change at the highest organizational level”.

Personal and professional advancements from the DNP program

Themes emerged that were independent of the eight DNP Essentials. Statements in the papers regarding personal changes that occurred from the program experiences were significant enough to include a section entitled the Personal and Professional Advancements from the DNP Program. Their educational journey helped redefine and enhance the development of their professional role. Students embraced a stronger professional identity, which helped them transcend to a new level of professional competence, responsibility and accountability. The themes, The DNP Journey and Pre-Program Perceptions were consistent threads throughout students' comments regarding their DNP journey, and how their preprogram perceptions changed from what they envi- sioned the DNP program to be to how the program experiences were life changing.

The DNP journey Program experiences shaped the DNP graduate in both personal and

professional dimensions. Students described the DNP educational journey as unforgettable, and one that caused enlightenment and pro- fessional growth. One student said, “This has been a time of transfor- mation for me, personally and professionally. My vision has changed, and I look at situations from a totally different aspect than I did pre- viously”. Transformational, amazing, overwhelmed, and unforgettable journey are words students used to describe their DNP journey. Students stated, “the DNP program has transformed me professionally and personally” … “The past years have been transformational” … “the [program] has been an unforgettable journey and one of the best de- cisions I have ever made” … “Pursuing my DNP degree has been an amazing endeavor.” The DNP program enlightened students with life changing ideas that deepened their commitment to the nursing pro- fession, and expanded their views of healthcare issues. “I am over- whelmed with so many emotions [and] thankful that I have been given this opportunity, as it has changed my life forever.”

Pre-program perceptions A consistent theme among students was an initial confusion about

the DNP program. Students described that they did not know prior to admission what DNP program really entailed, and what they were going to experience. One student stated, “I was uncertain how the program would influence my career trajectory, [and I] was unclear if the degree would provide professional advancement”. Students did not understand how the DNP program would benefit them professionally, and how the learning process would affect them; they “did not anticipate the di- versity of learning opportunities that would be provided”. As students who were already advanced practice nurses and with master's degrees, post master's students were skeptical about how much they could learn, as they perceived themselves to be expert clinicians. A CRNA student

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stated that, “it was difficult to see beyond the walls of the operating room (OR). I did not fully appreciate the purpose of the assignments in the beginning of the program. But now, as I reflect back on my edu- cation, I understand I was mistaken. My perspective of health care and understanding of the DNP has grown tremendously and exceeded my initial expectations in the past three years”.

Discussion

The themes that emerged from students' reflections show how the achievement of the DNP Essentials contributed to professional role development as well as personal growth. It is informative for student advisement reasons and curriculum development to understand the effect that the DNP program experiences have on the DNP students' growth. It is of value to faculty to appreciate the importance that a positive faculty-student relationship has on professional role develop- ment.

Bringing the DNP essentials to life

The DNP Essentials detail the curricular elements of DNP programs that lead to the competencies that DNP graduates should know and exemplify in order to address the complex and ever-changing needs of the healthcare system (American Association of Colleges of Nursing (AACN), 2006). Students reflections identified that they both learned and incorporated into their practice the importance of the competencies of the DNP Essentials. A common theme is that students learned how to use the concepts of DNP Essentials thought dialogue with faculty, other students, and colleagues in their work places.

The eight DNP Essentials published in 2006 (American Association of Colleges of Nursing (AACN), 2006) guided the development of DNP programs across the nation. The current revision process underway of the DNP Essentials to include 10 proposed domains strengthen the DNP Essential and acknowledge the need for the DNP curriculum to address the development of nurses' professional identify and professionalism, as well as personal, and leadership development to lead the profession in the healthcare industry (American Association of Colleges of Nursing (AACN), 2019). The relevance of the themes that emerged captures the growth in role attribution and professionalization that occurred as a result of the DNP program experiences. Identifying the effect of the DNP program on students' professional journey serves to increase under- standing of the impact that the DNP curricula, faculty program ex- periences, and student–clinician relationships have on the graduates' professional development.

Enlightening faculty

The faculty of DNP programs strive to provide a strong curriculum that challenges students to become competent clinicians who are lea- ders in the healthcare arena. While the faculty role includes being a content expert, role model, and mentor to DNP students, Anderson et al. (2019) identified challenges that faculty face, such as high number of students in DNP programs, resources, time constraints, and challenging workloads that can affect the quality of faculty-student interactions. These challenges can fatigue faculty and diminish the enthusiasm of the faculty-student interaction.

DNP faculty influence the development of DNP students' profes- sional identity in ways faculty may not envision. Students' reflections described how “amazing” DNP faculty were in their growth throughout the DNP program. It is important for faculty to understand the strength of the positive influence they have on the students (Andrew et al., 2009), and that the DNP curriculum and program experiences would not be possible except for the oversight that competent doctoral faculty provide to the DNP students and program.

Development of leadership

DNP Essential II: Organizational and Systems Leadership for Quality Improvement has a broad focus on leadership in healthcare organiza- tions and systems and aligns closely with developing the skill set needed to lead transformative change (American Association of Colleges of Nursing (AACN), 2006). In the DNP program, a student's understanding of leadership principles and becoming a leader in an organization involves an intersect between didactic content, practice connections where leadership in action is modeled, and mentors en- courage students that they are capable (Kendall-Gallagher and Breslin, 2013). For DNP students, the DNP curricula moved them to develop as leaders at all organizational levels. The theme of ‘Leadership Develop- ment’ emerged from reflection paper statements as students described their growing sense of understanding what leadership is and what a leader does. DNP program experiences instilled confidence for students to embrace their ability to lead within their healthcare organizations.

Evolving professional identity

Professional identity develops throughout a lifetime and con- tinuously changes and evolves during years of education and nursing experiences (Johnson et al., 2012). Students stated that the DNP pro- gram was the catalyst that helped them grow and change their pro- fessional identity. Students described how much they had learned and how that learning translated into improving their interactions with others in clinical practice by applying those principles to their practice, and mentoring of others. A positive professional identity that leads to a positive professional and personal image (Johnson et al., 2012) helped DNP students transcend to a new level of perceived competence, re- sponsibility, and accountability. Students' stated they were empowered, motivated, and inspired to make changes within their organizational settings that they would not have done prior to the DNP program. In- terprofessional collaboration, and heading quality improvement in- itiatives were skills that they felt professionally competent to lead.

Themes identified individual and collective levels of a socialization process where the students formed new and expanded perceptions of self in their professional roles (Jarvis-Selinger et al., 2012). Students identified how they incorporated the knowledge gained from program experiences into a stronger determination of what they, as DNP grad- uates, could do to promote the nursing profession, expand their lea- dership abilities to work with other related professions to improve their professional identity and healthcare outcomes.

The professional socialization that resulted from student's learning experiences took them to another level of professional understanding and commitment. Themes showed that students had new found per- ceptions of self, such as confidence, and leadership ability. The program reshaped their professional identity, both individually and collectively (Jarvis-Selinger et al., 2012), as there was a change in their perception of what they could accomplish and achieve in the healthcare system as a result of the DNP program.

Unanticipated gains from the DNP program

The category of Personal Advancements from the DNP Program en- compassed the themes described as The DNP Journey and Pre-Program Perceptions. The themes highlighted personal and professional growth ex- perienced during the DNP program and personal reflections on what stu- dents did not expect to achieve during the program. It is interesting to see that students prior to entering the program did not anticipate the trans- formational affect that the DNP program experiences would have on their personal and professional lives. The educational journey through the pro- gram changed student's vision of the world and caused enlightenment of understanding in many areas of professional practice. Students embraced confidence in their abilities which helped them transcend to new levels of professional competence, responsibility and accountability.

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From a DNP program perspective, it is instructive to appreciate that many students enter the program with little understanding of what they will achieve as a result of the DNP degree. Nurses who choose between DNP and PhD programs may have minimal understanding of what each program strives to achieve. Expert clinicians enter post master's DNP programs believing they are at the top of their professional game, and are skeptical as to what the program can offer them. However, students' reflections indicated they were mistaken by what they did not know and amazed at what they learned through the educational experiences.

Conclusion

The thematic analysis of students' written reflections describing professional growth and development, future as a DNP graduate, and changes in one's view of health care, identified how the curriculum and experiences in the DNP program shaped professional role development as well as personal perceptions of ability. The themes that emerged from the reflection papers identified how the richness of the DNP program experience helped students learn beyond what they thought possible, and how students were emboldened to move forward in the nursing profession as leaders and innovators to improve patient care at all levels of the healthcare system. Finally, the themes identified how the focus of the curricula on the DNP Essentials has served the pro- fession of nursing well in guiding the development of DNP programs to produce nurse leaders prepared to lead healthcare transformation.

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