Foundations and Essentials for the Doctor of Nursing Practice

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Research translation and the evolving PhD and DNP practice roles: A collaborative call for nurse practitioners

Ann C. Falkenberg-Olson, PhD (Nurse Research Scientist Consultant)

ABSTRACT Doctoral prepared nurse practitioners (NPs) are uniquely positioned for responsible leadership as essential mem- bers of the health care system and have a professional responsibility to contribute to research and clinical inquiry initiatives that advance health care delivery and improve outcomes. Academic preparation of the Doctor of Phi- losophy (PhD) and Doctor of Nursing Practice (DNP), although different in focus, offers opportunities for effective collaborations that transcend and integrate the scientific and practice roles of generating data and translating evidence. As health care organizations evolve in managing complexities of providing high-quality care, roles for the PhD as research scientist and DNP as research translation specialist will also evolve to keep pace. Despite this professional calling and global opportunity for research and evidence-based practice (EBP), future NPs and nurses will be challenged with an imminent lack of experts who have the skills needed for data and research generation and evidence translation. This commentary introduces and discusses emerging roles and organizational models for doctoral prepared NPs in research, EBP, quality assurance, and quality improvement projects, offers suggestions for NPs interested in research and clinical inquiry, and seeks to ignite excitement for scientific discovery in NP-driven initiatives. Nurse practitioners are encouraged to take advantage of the many opportunities to shape and expand their careers by engaging in knowledge generation for improving health care outcomes. Keywords: DNP; doctor of nursing practice; nurse practitioner; PhD; role collaboration; research scientist; research translation.

DOI# 10.1097/JXX.0000000000000266

Introduction Within the past few decades, various leaders throughout the US health care system began calling for trans- formative changes that directly implicate the discipline of nursing and the professional role of contemporary nurse practitioners (NPs). As NPs, we are positioned for re- sponsible leadership by engaging as full partners in supporting and sustaining the triple aims of excellence in patient care experiences, improved population health outcomes, and pragmatic use of health care resources. The Institute of Medicine Future of Nursing states that nurse leaders need to function at the full scope of prac- tice within health care teams and participate in and guide research initiatives to generate new knowledge- and evidence-based improvements that translate research findings into practice (Altman, Butler, & Shern, 2016).

Nursing is a research-based profession that builds on the practice of its science (Henly et al., 2015) with an ex- pectation that NPs support nursing science by partici- pating in research (American Association of Nurse Practitioners [AANP], 2013). Despite this professional calling for research-based practice, future NPs and nurses face an imminent lack of experts with the skills needed for data and research generation and evidence translation (Wysocki, Underwood, & Kelly-Weeder, 2015). Data exploring academic doctoral nursing programs from 2008 to 2017 foresee future opportunities and challenges for nurses interested in research careers. Since 2014, enrollment in Doctor of Philosophy (PhD) nursing pro- grams has decreased by 9.6%, and PhD graduations in- creased by 43%. Conversely, within the same time frame, Doctor of Nursing Practice (DNP) enrollments increased by 752%, and DNP graduations increased by 1,587% (American Association of the Colleges of Nursing, 2018). An estimated “2%of the nursing population have doctoral degrees despite great demand for these individuals to serve as advanced practice registered nurses (APRNs), assume faculty roles, embark on careers as research scientists, and pursue leadership roles (Budden, Zhong, Moulton, & Cimotti, 2013; Howard & Wilson, 2016)”

Department of Nursing Research, Gundersen Health System/Gundersen Medical Foundation, La Crosse, Wisconsin Correspondence: Ann C. Falkenberg-Olson, PhD, Department of Nursing Research, Gundersen Health System/Gundersen Medical Foundation, La Crosse, WI 54601. Tel: 608-775-2758; 507-450-0471; E-mail: [email protected] Received: 11 February 2019; revised: 21 May 2019; accepted 29 May 2019

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Commentary

(Trautman, Idzik, Hammersla, & Rosseter, 2018, p. 2). These trending statistics serve as a responsible call for action among NPs. In anticipation of fewer experienced PhD- prepared nurses in the workforce, we must plan creative ways to develop new nursing knowledge and translation that keeps pace with the growth and changing complexity of health care. As NPs, how do we seek out and contribute to this professional and ethical responsibility in our busy practices?

We can improve this translation gap by supporting, developing, and sustaining collaborative efforts among doctoral-prepared NPs in scientific methods, clinical scholarship, program development, organiza- tional and system theories, health policy, and in- novation (Carter, Mastro, Vose, Rivera, & Larson, 2017; Vincent, Johnson, Velasquez, & Rigney, 2010; Wysocki et al., 2015). We must be committed to the highest quality processes and outcomes for the roles of NPs within the research-to-practice gap. In the spirit of this journal’s special edition on professional issues for NPs, this commentary introduces and discusses emerging roles for doctoral-prepared NPs in research and evidence-based practice (EBP) and seeks to ignite excitement for innovation in scientific discovery in NP- driven research initiatives.

Opportunities and challenges for nurse practitioners in nursing research Have you had the “experience of wondering” within your NP practice? Do you sometimes wonder if the “nursing” component of your practice is missing, diluted, or dis- counted? The following are examples of common ques- tions that NPs may encounter.

“Why do we do it that way? What would happen if we did it this way?”

“Our providers all approach this (e.g., procedure, condition, or diagnosis management) differently … why? What approach is best for our patients?”

“In my practice, it seems like most of the patients with (e.g., condition; diagnosis) have (e.g., symptoms; complaints; laboratory results; medical or family his- tory). I wonder if there might be some connection.”

“The clinical tool that we are required to use for (e.g., condition; admission diagnosis) doesn’t help us predict which patients are at highest risk for (e.g., condition; adverse outcome). I wonder if we could come up with a better one.” If you or your colleagues have any of these or similar

thoughts, you are experiencing “clinical inquiry” and may be on your way to expanding your professional career. Clinical inquiry reflects innovative thinking that jump-starts the EBP process between what we know (evidence) and what we need in our practice to fill the

gap (Ackerman, Porter-O’Grady, Malloch, & Melnyk, 2018).

Why should NPs be involved in research? Despite a possible response, “What … me? What could I possibly contribute to research?”, our work and role as NPs create countless opportunities to participate in EBP and quality improvement (QI) projects, in clinical nursing research, on interdisciplinary and transdisciplinary program development teams, and in entrepreneurial roles as consultants. Two research-related innovations that pose broad and deep impact on overall health of future generations are knowledge discovery through data generation and the evolving collaborative roles of nurses with doctoral degrees.

Data generation and knowledge discovery Our standards of practice are firmly grounded in the foundational model of nursing in assessing, diagnosing, and treating human response with advocacy in caring for individuals, families, communities, and global so- cieties (Brennan & Bakken, 2015). This deep integration of the foundation of nursing is vital for NPs in fully contributing to health care outcomes. We also in- corporate medical care into our practice using a framework of assessment, diagnosis, treatment plan development and implementation, and evaluation with follow-up (AANP, 2013). How are these contributions measured?

Data management is one of the most critical areas in nursing science that directly influences research and practice at all levels of care. Historically, the discipline of nursing and its practice were basedmore on tradition than on evidence, which led to robust professional initiatives in developing and using data in EBP and translational research (Jones, 2016). Measurement of nursing outcomes using valid and reliable data is cen- tral to all research-related activities that inform EBP. Electronic health record (EHR) systems contain abun- dant data; however, the use of the EHR to document nursing’s contribution to health care outcomes through “discoverable, consistent, and measurable data” (Clancy & Gelinas, 2016, p. 423) presents unique chal- lenges. Traditional nursing documentation lacked standardization of terms, used subjective free text often specific to unit or specialty, and was not usable for capturing and comparing standards of care, for reliable data extraction in research (Clancy & Gelinas, 2016; Westra et al., 2014) or for contributing to shared “big data” and data science initiatives (Brennan & Bakken, 2015). Doctoral nurses with expertise as both clinician and researcher can lead initiatives to develop common nursing nomenclature that will assist in designing ef- fective research and clinical translation of reliable ev- idence (Wysocki et al., 2015).

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Research translation and the evolving PhD and DNPCommentary

Doctoral prepared nurses: Emerging roles The Doctor of Philosophy (PhD) and the DNP are two contemporary nursing doctoral degrees. As terminal professional degrees, the PhD and DNP roles are com- plementary, not competitive, partners in reducing the knowledge gap through scholarly methods of inquiry and dissemination at the highest level of nursing preparation (Trautman et al., 2018; Wysocki et al., 2015). Although the PhD and DNP roles vary in focus, this variance offers vast opportunities for research and evidence-based collabo- rations with great potential for sustained impact on health care. Both roles contribute in producing data that inform and influence clinical practice (Cowan, Hartjes, & Munro, 2019; Trautman et al., 2018). The functional domains of each role are clarified by the terms research scientist (PhD) and research translation specialist (DNP) as influenced by Vincent et al. (2010).

PhD as Research Scientist The PhD in nursing represents the highest level of edu- cation for a role of scientific discovery that incorporates data development management. The PhD academic cur- riculum is globally established and prepares nurses to conduct independent research, producing data that can be translated into practice to advance all levels of health care through improved processes and effective health policy. Main doctoral courses focus on nursing theory, legislative and regulatory compliance, research methods and applied statistics, and program development (Cowan et al., 2019). In advancing the traditional nurse scientist role, the PhD research scientist has the key responsibility in working with nursing organizational clinical leadership to shape a culture of inquiry through mentoring, guiding research development, developing a program of re- search, and participating in EBP and QI projects (Brant, 2015; Cowan et al., 2019; Vessey, McCabe, & Lulloff, 2017). As a contemporary research scientist, the PhD-NP has clinical experience that informs a program of research and fosters a keen appreciation of the importance of translational research (Wysocki et al., 2015). This combi- nation of scientific training and clinical practice experi- ence opensmany opportunities for this highly skilled and educationally prepared nursing professional to uniquely participate in research initiatives within full scope of practice.

DNP as Research Translation Specialist The DNP academic curriculum was developed to recog- nize gaps in nursing practice within modern health care system complexities and to develop new practice knowledge and leadership skills that improve health care delivery (Cowan et al., 2019; Vincent et al., 2010). Main DNP courses focus on EBP process, implementation and evaluation, leadership development, translational

research integration, and QI (Vincent et al., 2010). In contributing to role development of the research trans- lation specialist, the DNP has the key responsibility in assessing organizational readiness for change, trans- lating evidence (data) into practice using implementation science, and contributing to research initiatives when new knowledge needs to be developed (Trautman et al., 2018). As an evolving DNP research translation specialist, the NP has in-depth clinical experiences and skills in interdisciplinary communication, patient engagement, and organizational culture that can contribute uniquely to advancing knowledge (Wysocki et al., 2015).

Scenarios Two scenarios, partially informed by the author’s expe- riences, illustrate PhD- and DNP-prepared nurses’ col- laboration in research process and clinical application. These scenarios reflect how collaborative PhD–DNP roles can effectively address practice change within the disci- pline, as well as inform program development within a transdisciplinary approach.

Scenario A: Fall risk prediction among adult inpatient neuroscience patients with cerebral vascular accident. An in- patient unit of neuroscience nurses determined that the clinical nursing tool to predict falls among adult patients admitted with recent cerebral vascular accident (CVA) was inadequate. These staff nurses brought this issue to their leadership team (acute care adult NP [DNP], clinical nurse leader [CNL], nurse educator, and nurse manager) who reviewed the issue and agreed to further inquiry. The DNP and CNL applied the IowaModel of EBP to this clinical inquiry and led unit practice committee registered nurses (RNs) in discussions, literature searches, and evaluation of the evidence. Clinical concepts were selected from the literature (e.g., adults, neuroscience diagnoses of interest, specific fall risk prediction tools), and related quality data were evaluated for clinical relevance by expert RN con- sensus. High levels of evidence for several tools pre- dicting falls were found, but none were specific to the adult neuroscience CVA inpatient population. At this point in the process, the DNP consulted with a PhD re- search scientist in the health care system’s nursing re- search department. After discussing the phenomenon of interest, the clinical question and context, and the liter- ature and review of evidence, the DNP and PhD agreed that the evidence was not strong enough to safely im- plement and evaluate a new prediction tool in this pop- ulation and elected to continue the inquiry using a research process. The PhD and DNP further ascertained that a prospective study would be cost prohibitive and requested that further quality-indicator data be pulled to determine whether valid data were retrievable and whether a retrospective study design was feasible. The PhD consulted a statistician who agreed to collaboratively review and analyze all data. A study design

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was approved by the institutional review board (IRB) that incorporated protocol using quality data and EHR review by expert RNs to match data specific to the identified nursing concepts to determine face and content validity. Preliminary findings show promising results that may inform fall prediction tool development and support research specific to this neuroscience population.

Scenario B: Maternal substance use disorder and family- centered care in an ambulatory specialized pediatric department: Data development. In response to a growing issue of substance use disorder (SUD) among pregnant women and its generational effect, a clinical team (pediatricians, RNs, social workers, child psychologists, and several NPs) within a tristate, multidisciplinary, health care organization (HCO) pediatric clinic focused their outpatient practice on infants and children of mothers with a history of SUD. Overall program goals were to promote and provide a healthy and safe environment for children born to women with SUD by providing mothers with skills to effectively care for their child and subsequently prevent childhood maltreatment and to maintain custody. After two years of providing care, the clinical team wanted to know if their comprehensive program was associated with improved selected program outcomes (e.g., infant anthropometric measures, vacci- nation rates, clinical appointment attendance, maltreat- ment, adverse childhood events, and child custody). A pediatric NP–DNP and the program RNs approached the clinic’s nursing research department who used the Iowa Model to operationalize the clinical inquiry process. A literature review of the program’s questionnaires and clinical concepts, discussions with the program team, and a representative sample of de-identified EHRs revealed solid medical data with appropriate nursing assessments and interventions. However, reliable and valid nursing data were not retrievable through quality reports to sufficiently address the clinical team’s inquiry. To address the gap in capturing program data that reflected nursing interventions, two PhD research scientists collaborated with the DNP-NP and pediatric clinical team in developing an IRB-approved research- based proposal focusing on program outcomes. A grant proposal was written to offset the time-intensive costs of an expert pediatric RN’s assigned work with the research scientists to generate data and establish face and content validity in linking EHR text notes with common terminology. From this collaborative work, a research database was developed and used to describe and measure program outcomes and to provide evidence for future program development. A preliminary comparative study shows promising evidence in several pediatric outcomes and informed a qualitative mixed-methods study to further examine parental and caregiver perceptions.

Contemporary organizational models for nursing Research initiatives The evolving role of NPs provides a great fit for developing new data and translating research directly into practice (Wysocki et al., 2015). Contemporary NPs can serve as re- search or project investigators and leaders ormembers of interdisciplinary and transdisciplinary teams focusing on a wide range of clinical projects and translational re- search (Cohn, McCloskey, Kovner, Schiffman, & Mitchell, 2018), as well as work collaboratively to sustain a culture of inquiry within organizations (Brant, 2015). This “culture of inquiry” is evidenced when NPs and nurses in all positions, roles, and units perceive and experience value in sharing new ideas while being encouraged and sup- ported to use research in their clinical practices (Brant, 2015). Health care organizations within this culture of inquiry often develop and maintain nurse research departments or councils that are self-governed and use a translational model (e.g., Iowa Model Collaborative, 2017; Johns Hopkins Nursing Evidence-Based Practice Model, 2017). A translational model guides innovation and re- search into practice and encourages and provides men- torship for research, EBP, and QI projects (Brant, 2015; Cohn et al., 2018; Vessey, McCabe, & Lulloff, 2017; Wilson, Kelly, Reifsnider, Pipe, & Brumfield, 2013).

Advancing clinical inquiry is vital in our health care system’s rapidly changing environment. The NP as re- search scientist or research translation specialist can function at full capacity of academic preparation and within full scope of professional practice in collabora- tively generating data and translating nursing research into effective clinical practice. Table 1 shows an overview of several contemporary organizational models for col- laboration between the PhD research scientist and DNP research translation specialist. Potential opportunities and challenges for the HCO and for the research role are listed, with references cited in the “notes.” For the NP interested in research initiatives, suggestions are offered for each model.

Inhouse PhD Research Scientist Many HCOs use at least one PhD research scientist whose main role is to conduct an original research program pertaining to a clinical issue central to the institution’s mission and vision with a secondary role of staff de- velopment. The research scientist has direct access to staff, may serve on various research/IRB and nursing council committees, and expands HCO external visibility through professional associations, dissemination of re- search, and grant proposal submissions and awards. The PhD serves as mentor and resource to staff involved in research, thus enhancing staff engagement and retention and can directly collaborate with DNP research trans- lation specialists in EBP and QI projects that reflect full

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scope of nursing practice. This role allows opportunity for effective interdisciplinary and transdisciplinary research that aligns with the HCO mission. Despite many inter- actions with staff, a sole PhD research scientist may be

isolated from peers and will benefit from external col- laboration with colleagues in similar roles.

A successful inhouse PhD model needs strong HCO leadership support of nursing research. Funding

Table 1. Organizational nursing models and roles of the Research Scientist (PhD) and Research Translation Specialist (DNP): Opportunity and challenge

Model

HCO Nursing Role

Opportunity Challenge Opportunity Challenge

Inhouse scientist PhD

PhD part of organizational structure with staff accessibility1–3

Cost1,2 PhD access and mentoring to DNPs and nursing staff allow mutual full scope of practice3

Possible role isolation; PhD may need to collaborate with external peers1

HCO visibility via PhD–DNP involvement in external organizations1,2

PhD area of interest2 Expand program of research3

PhD serves on research- related committee(s)1

Leadership support1,2

Mentoring recognizes staff contribution1,3

Not recognizing or supporting intangible unseen work may interfere with role success1,2

Enhanced staff engagement and retention3

Staff time, priorities, and project timelines1

Academic–practice partnership

Shared/access to organizational resources1–4

Limited time availability of university faculty/ students2

Direct research access to real-world data, patients/health records2,4

PhD and DNP need to balance priorities2

Less costly2 Needs strategic communications for sustainability2,3

Potential supplemented salary2

Organizational collaboration in grant opportunities2,4

PhD and DNP professional development4

Staff nurse engagement3

Nurses as possible coinvestigators/adjunct faculty1,3,4

Consultant Specific research or project focus2

Managing activities/ mentorships2

Workload flexibility2 Mentoring multiple projects2

Less costly2 Consultant fees may need funding3

Expertise strengths2 Potential extended time for project completion2

PhD available to staff2,3

Limited understanding of HCO culture and processes2

Notes: Citations in reference list: 1Brant (2015), 2Vessey, McCabe, & Lulloff (2017), 3Wilson, Kelly, Reifsnider, Pipe, & Brumfield (2013), and 4Cowan, Hartjes, & Munro

(2019). DNP = Doctor of Nursing Practice; HCO = healthcare organization; PhD = Doctor of Philosophy.

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shortage, nursing staff clinical priorities, lack of dedicated research time, changing mission focus that no longer supports a programof interest, and not distinguishing the intangible “behind-the-scenes” work associated with the role can be organizational barriers.

Simple suggestions If your HCO has an inhouse department of nursing re- search or has at least one PhD research scientist on staff, make an appointment to discuss mutual interests that may lead to future collaboration. Also, get to know your HCO DNPs by organizing a discussion meeting or getting involved in groups or committees that promote the re- search translation specialist role. Learn more about and participate in research-related or EBP and QI opportu- nities. Remember, we have a responsibility as NPs to contribute to nursing science.

Academic–Practice Partnership Academic–practice partnerships represent a model that may proficiently integrate research initiatives across institutions. These partnerships are defined as formal or informal agreements or strategic relationships between and among clinical practice and academic institutions developed to advance mutual goals in education, prac- tice, and research initiatives (Beal, 2012). These relation- ships range from highly structured with formal contracts clarifying partnership member roles, strategy, and finances to informal as-needed agreements for short- term projects delineating partnering academic and clin- ical staff roles. As part of its mission that recognizes and values contributions of research, any HCO or academic institution can foster opportunity to engage in some level and scope of cooperative nursing academic–practice partnering. Promoting PhD–DNP collaboration while de- veloping or sustaining a partnership enhances access to shared physical and human resources, including grant proposal development, and creates shared potential roles as coinvestigators or adjunct faculty. This model is usually less costly to an HCO than an inhouse PhD re- search scientist model, but it also may encounter time- availability constraints due to academic calendars of faculty and students. When developing or sustaining in- formal agreements, smaller HCOs may need to rely on ad hoc opportunities and short-term projects to sustain energy and enthusiasm of the collaboration.

Academic–practice partnerships provide a platform for PhD–DNP roles with potential for enhanced pro- fessional development, potential supplemental income, and access to real-world data. This partnership model has great capacity for HCOs to maximize internal resources and optimize patient care outcomes but necessitates an organizational culture that supports the unique and interrelated contributions of the PhD and DNP roles. To sustain a successful partnership,

organizational partners must be committed to strategic communications that include timely assessments of mutual and individual goals.

Simple suggestions If your organization engages in academic–practice part- nering, take advantage of opportunities to share with and learn from your collegial partners. Talk about your “burning clinical questions” with other NPs, pursue membership on councils and internal or partnership committees that are research based, seek out nurses or researchers who share your clinical interest, and attend and participate in poster sessions that showcase your work. Get to know the leaders of research, EBP, and QI by attending Grand Rounds or other dissemination-related activities. You have many opportunities to get involved within this dynamic evolving model. Remember, NPs are in key roles and have professional responsibility to assist in translation of research.

Consultant as entrepreneur Evolutionary changes in our health care system are cre- ating innovative research prospects for PhD- and DNP- prepared NPs to generate new knowledge and to guide translation into practice. The term entrepreneurship is defined by the Cambridge Dictionary (2018) as “skill in starting new businesses, especially when this involves seeing new opportunities.” Nurse entrepreneurship is defined by Arnaert, Mills, Bruno, and Ponzi (2018, p. 1) as “independent practice of business proprietors that offer direct care or consultation services and are directly ac- countable to the clients they serve.” The research con- sultant role is time and project specific and provides accessibility to HCO staff. External consultants have legal contracts that specify project scope and objectives. Re- search consultant fees may need grant or other funding but are usually less costly to the HCO than an inhouse PhD research scientist or academic–practice model. Al- though the consultant entrepreneur may take on various contracted projects simultaneously and will need to be oriented to HCO cultures, this role offers workload flexi- bility to the consultant who can focus project scope and objectives based on expertise strengths.

Simple suggestions Nurse practitioners with doctoral degrees are in key positions for innovative collaborations with many organizations and industries. Attend professional con- ferences in your clinical specialty or research societies to network with others who have similar interests and pas- sions. Learn more about business planning associated with your ideas. If your organization has a doctoral pre- pared nurse research consultant, learn more about their professional journey. Read about NPs who are entrepre- neurs, such as one PhD-prepared NP who received an

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award for the coinvention of a point-of-need clinical tool that tests for infectious pathogens (National Institute of Nursing Research, 2018). Remember, clinical inquiry drives many careers.

Conclusion The need for doctoral prepared nurses to develop data for translation into practice will grow. Nurse practitioners are essential members of the health care system and have a professional responsibility to contribute to re- search initiatives that will advance health and quality of care and add to value. Academic preparation of the PhD and DNP in nursing offers opportunities for effective collaborations that transcend and integrate the roles of generating data and translating evidence. As HCOs evolve to address the constant changes and challenges of health care needs at all levels of care, roles for PhD research scientists and DNP research translation specialists will also evolve to keep pace. Nurse practitioners have abundant resources and are encouraged to take advan- tage of the many opportunities to shape their careers by participating in research initiatives and engaging in knowledge generation for improving health care outcomes.

Competing interests: The author reports no conflicts of interest.

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