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transform nurse practitioner education and practice

Mary Ann Draye, MPH, ARNP

Michele Acker, MN, ARNP

Phyllis Arn Zimmer, MN, ARNP, FAAN

Ongoing challenges caused by increased com-plexity of care, changing patient demographics, and shifting health care delivery systems are neces-sitating a transformation of advanced practice. The practice doctorate has the potential to prepare graduates to meet these challenges now and in the future. This article conceptualizes the practice doc-torate curriculum for nurse practitioners (NPs), with particular focus on how it will prepare NPs as expert clinicians with enhanced leadership and research skills. Nurse practitioner doctoral education and practice is articulated and differentiated from cur-rent NP education and practice, with distinguishing features clearly identified. A compelling argument is made for how this educational preparation will fa-cilitate NPs in meeting future societal needs. The purpose of this article is to provide guidance for all advanced practice educational programs consid-ering adoption of a practice doctorate, and to contribute to the advancement of thinking about the practice doctorate for clinicians as well as educators.

T

he dynamic interaction between nursing educa-tion and nursing practice has generated remark-able advances in health care and in the nursing profession. Education and practice each provide di-rection: educational emphases influence best prac-tices in clinical arenas and, likewise, demands from practice influence the breadth, depth, and ultimate focus of educational offerings. This dual, relational input propels the profession to achieve greater levels

of educational quality as well as improved health outcomes.

Nursing education is now poised to provide remark-able new direction in advanced practice from imple-mentation of the practice doctorate.1 Increased demand for services, growing complexity of care, continuing health disparities, and changing population demograph-ics indicate deep societal need for a new health system,2 and countless articles and reports emphasize the need to better prepare the health care workforce.2–5 These demands virtually mandate educational reform. Educa-tors recognize that current advanced practice education is inadequate to prepare advanced practice nurses to meet future healthcare needs or improve the system of care delivery. Critical to changing health systems and achieving improved health outcomes is the preparation of advanced practice nurses as clinical leaders who can provide expert care.

In light of these mounting challenges, the University of Washington (UW) School of Nursing (SoN) Practice Doctorate Task Force embarked on a re-conceptualization of graduate education for nurse practitioners (NPs). In the Practice Doctorate Task Force’s analysis, a practice-oriented doctoral degree, rather than the research-practice-oriented PhD, will best support NPs desiring to become expert clinicians and leaders. Initial curriculum discussions cen-tering on direct, individually-focused clinical care eventu-ally expanded to include care of families, communities, and populations, as is consistent with the American Association of Colleges of Nursing (AACN) Position Statement on the Practice Doctorate: “focus [may be] on any form of nursing intervention that influences health outcomes for individuals or populations.”1 Thus, the practice component of the degree will vary. For example, while students focusing on community health systems nursing will be prepared with advanced skills in the care of populations and communities, clinical nurse specialist, nurse midwifery, and NP students will focus on expert clinical care of the individual/family. All graduates will be prepared for a tripartite role: expert clinician, clinical leader, and researcher, with a focus on practice inquiry. 5,6 The remainder of this discussion will center on the practice doctorate curriculum as it relates to NP education. Mary Ann Draye is an Assistant Professor, Director of the Family Nurse

Practitioner Program, Department of Psychosocial and Community Health at the University of Washington School of Nursing, Seattle, WA.

Michele Acker is a Senior Lecturer, Director of the Pediatric Nurse

Practitioner Program at the University of Washington School of Nursing, Seattle, WA.

Phyllis Arn Zimmer is a Lecturer, Family Nurse Practitioner Program at

the University of Washington School of Nursing, Seattle, WA. Reprint requests: Mary Ann Draye, University of Washington SoN, Box 357263 Seattle, WA 98195

E-mail: drayema@u.washington.edu Nurs Outlook 2006;54:123-129.

0029-6554/06/$–see front matter

Copyright © 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.outlook.2006.01.001

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Academic Evolution: From

Certificate to Doctorate

Early NP education such as the seminal work by Ford and Silver in Colorado typically began as certificate preparation, with some programs based in health care institutions and others in academic settings. From these beginnings, NP education quickly evolved to master’s level preparation with standardized compe-tencies and certification requirements.7 Currently, to accommodate NPs’ expanded scope of practice and assumption of greater responsibility for care, NP curricula have inflated and required credits have skyrocketed to the extent that a master’s degree is rarely commensurate with time spent and credits earned. In contrast, the practice doctorate awards a degree proportionate with student effort and depth of learning.

Many NP faculty members regard the practice doc-torate as the “next step” in the evolution of NP education not only in terms of equity for effort, but moreover because it prepares students for new dimen-sions of practice rather than merely “adding on” courses to a master’s degree program. As clinical competence is key to the success of the NP role, clinical content in the practice doctorate will expand present content regard-ing health risks and self-management of chronic illness. New content will be added to address the explosion of scientific and technological advances impacting clinical decision-making, incorporation of alternative or com-plimentary therapeutic options in allopathic models of care, deep integration of mental health care, advanced

interpersonal skills with families and groups, and ex-tended clinical hours.

In addition to increased clinical competency, the NP of the future must have the ability to generate and manage change. Such innovation requires advanced knowledge of inquiry to study and interpret practice outcomes, as well as leadership skills to guide the change process. Thus, the practice doctorate at the UW will include 2–3 times the practice inquiry and leadership content of a typical master’s degree pro-gram. This rich curriculum will provide the basis for fuller utilization of NPs in practice, care delivery, and policy arenas. It is anticipated that, much like the pioneer NPs did 40 years ago, doctorally prepared NP clinical experts engaged in practice-focused re-search and leading change will shape health care delivery and quality once again.

Conceptualizing the Practice

Doctorate Curriculum

Re-conceptualizing graduate education for NPs re-quires collaboration with faculty colleagues across programs. Faculty members at the UW SoN began discussion by affirming the fundamental assumption that nursing is a scholarly discipline, and then af-firmed a set of educational and practice assumptions underlying a practice doctorate curriculum. (See Table 1 and Table 2.) AACN recommends a curric-ulum leading to expertise in at least one area of specialized advanced practice.1 Consideration was given to curriculum efficiency, effectiveness, and

Table 1. Underlying Assumptions About NP Education for the Practice

Doctorate Curriculum

1. Nursing is a scholarly discipline.

2. The curriculum will prepare a direct care provider.

3. An expanded curriculum will broaden the preparation of the graduate not only for clinical practice but leadership, clinical research, and clinical teaching.

4. The curriculum is multi-layered: shared doctoral content; shared advanced practice core; advanced practice specialty content; sub-specialty content; interest areas. 5. Specialty foci will match areas of national certification; options for sub-specialty can be

done through course selection, focus of clinical residency, scholarly portfolio, and capstone clinical investigation.

6. The clinical management portion of the curriculum will be grounded in evidence and incorporate clinical practice guidelines. Progression is competency-based.

7. Selected courses will move toward problem-based learning with emphasis on how to manage knowledge, critical thinking, and approaches to support clinical decision-making.

8. Faculty will continue to be involved in clinical learning activities with students.

9. Students can be admitted via multiple entry points; for example, with a baccalaureate in nursing or in another field, or as a post-masters or post-doctorate student.

10. Mechanisms will be in place to expedite doctoral preparation for master’s-prepared NPs currently in clinical practice or teaching in NP programs.

11. Opportunities will be expanded for interprofessional learning in classroom as well as clinical settings.

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flexibility as well as logical sequencing of content based on knowledge and skill acquisition. Therefore, the envisioned practice doctorate curriculum at the UW features a consolidated focus area of study for NP students at initial entry, allowing for develop-ment of a sub-specialty later in the curriculum. Table 3 depicts how the areas of study in this practice doctorate curriculum correspond with possible certi-fication.

With advanced clinical practice, leadership, and practice inquiry as its foundation, the UW curriculum was developed further, building upon existing areas of strength and addressing gaps. Many practice compo-nents of current NP curricula remain relevant (eg, health assessment, health promotion, clinical manage-ment) and will be transitioned into doctoral preparation. Other aspects, however, are lacking or need strength-ening, including complementary and alternative medi-cine, genetics, advanced preventive interventions, pol-icy, and clinically applied informatics. Key elements of doctoral education for practice are presented in Table 4. The multi-layered curriculum outlined in Table 5will provide all students with core research, leadership, and policy content, shared advanced practice content (health

assessment, health promotion, illness management, etc), specialty and sub-specialty content (acute care, occupational health, geriatrics, etc), and content in interest areas such as disease states (diabetes, asthma, heart disease, HIV/AIDS, etc.), informatics (organiza-tion, storage, access, and analysis of health care infor-mation), practice management, genetics, rural health, etc.

The UW practice doctorate curriculum also includes a long overdue intensive clinical, referred to in this article as clinical residency, meeting the need for more clinical experience expressed by many graduates and their employers. The residency is viewed as an integra-tive experience, encompassing the 3 components of the tripartite role: not only the delivery of expert clinical care, but leadership in inter-professional teams, and practice-based research. Residency placements that support the transformation of the NP role will be necessary, possibly requiring innovative community partnerships. An enhanced Learning Center will support student development of clinical skills using simulated patients and fostering the integration of technology with laboratory experiences.

Table 2. Underlying Assumptions about NP Practice for the Practice

Doctorate Curriculum

1. Nurse practitioner practice is both autonomous and interdependent.

2. Nurse practitioners are accountable as direct providers of nursing care services. 3. Nurse practitioners provide care in a variety of settings using multiple practice models. 4. Nurse practitioner care is focused on health promotion and health restoration, as well as on

assisting patients/families to self-manage disease conditions.

5. Caring, patient/family health education and counseling, and advocacy are hallmarks of nurse practitioner practice.

6. The translation of science into practice is reflected in care provided by nurse practitioners.

Data from original NONPF Advanced nursing practice: Curriculum guidelines and program standards for nurse practitioner education. Washington, DC. April 1995.

Table 3. Focus Areas of Study in a Practice Doctorate Program

Initial Focus for Entering Student

Example Sub-specialty Options Built on Initial Focus

(Leads to specialty certification)

(May lead to added certification if didactic & clinical requirements are met)

Example Elective Interest Areas Adult NP Family NP Pediatric NP Psychiatric/Mental Health NP Nurse Midwifery Neonatal NP

Clinical Nurse Specialist Community Health

(certification under review)

Acute Care NP Geriatric NP

Women’s Health NP

Occupational/Environmental Health Children with Special Needs

Specific Disease States (diabetes, etc.) Informatics Genetics Forensics Rural Health Education Policy

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Distinguishing Features of Doctoral

NP Practice

An NP prepared in a practice doctorate program will be distinguished from a master’s-prepared NP by the increased breadth and depth of his or her practice, and by the integration of clinical leadership and inquiry in the NP role. Doctoral preparation provides greater opportunity than master’s preparation to shape the

nature of advanced practice nursing. Doctorally pre-pared NPs will have additional time to explore nursing and health-related theories that guide and inform prac-tice. Scholarly clinical investigation and advanced courses in patient management will provide opportuni-ties to apply and examine nursing concepts related to advanced practice. Finally, with cultural proficiency integrated into all its curricular elements and rich,

Table 4. Key Elements of Doctoral Preparation for Practice

Advanced Practice Leadership

Research/Practice Inquiry

Informatics

Cultural competence

Advanced Health Assessment Health Promotion

Behavior Change Family-oriented Care

Interpersonal Skills/Counseling

Evidence-Based Disease Management Nutrition

Pharmacology

Advanced Anatomy, Physiology Pathophysiology/Genetics Interprofessional Learning Clinical Practice/Residency Community Health Populations at Risk Informatics Cultural competence Health Policy

Health Care Access and Utilization Health Organization and System

Analysis Leadership/Professional Issues Ethics Practice Management Quality Assurance Informatics Cultural competence Design and Methods Nursing Science Program Planning and

Evaluation

Clinical Investigation Related Fields

*Elements do not necessarily represent separate courses but rather content areas. Crossover of content may occur between the 3 major areas of the curriculum.

Table 5. Practice Doctorate: Curriculum Layers

Curriculum Layer 1

Core Research, Policy, Leadership Content (All students)

Research/Practice Inquiry: Research Methods, Design & Statistics, Outcomes Research, Capstone Investigation

Policy and Leadership: Advanced Practice Leadership Role, Professional Issues, Health & Social Policy, Community/Population-Based Care

Curriculum Layer 2

Shared Advanced Practice Content (Individual-Focused Specialties)

Scientific Underpinnings (anatomy, pathophysiology, genetics, nutrition, etc.)

Advanced Health Assessment Health Promotion

Behavorial Health Illness Management

Complementary/Alternative Medicine Pharmacology

Interpersonal Communication (individual and family/group)

Curriculum Layer 3

Specialty Content

Specific courses/clinical experiences leading to certification as an FNP, ANP, PNP, NM, PSNP, NNP, or CNS

Curriculum Layer 4

Sub-Specialty Content

Courses in: geriatrics, women’s health, children with special needs, occupational health, acute care, etc.

Curriculum Layer 5

Elective Interest Areas

Menu of courses in: Informatics, Education, Specific Disease States, Forensics, Rural Health, Business/Practice Management, etc.

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diverse learning experiences, doctoral preparation will enhance culturally competent care here and abroad. Detailed exemplars of how the practice doctorate cur-riculum translates into enhanced NP practice follow: Interpersonal Skills

The practice doctorate curriculum will educate NP students to use an array of techniques to refine their ability to establish effective relationships with patients and families, working with them holistically as partners in their care. The development of a deeper awareness of self in interpersonal transactions will be fostered in a sequence of advanced courses in preventive interven-tions and interpersonal communication, beginning with the individual and progressing to families and groups. These courses will use innovative teaching methods, including the use of simulated patients, interactive video, observed patient encounters, and reflective jour-nals to facilitate the development of interpersonal skills ranging from empowering patients across diverse pop-ulations to analyzing how program and policy develop-ment can impact therapeutic relationships.

Behavioral Health

Health promotion and disease prevention content in the practice doctorate curriculum will feature higher division courses, clinical work, and scholarly projects. Many health problems such as obesity, cardiovascular disease, and asthma have a behavioral health compo-nent related to lifestyle decisions. Care management for these patients requires NPs who can effectively apply theoretical models of behavior modification to practice; the curriculum for the practice doctorate will feature comprehensive coursework in evidence-based strate-gies for behavior change. The program will also prepare NPs to design, initiate, and evaluate innovative pro-grams that support preventive services, leading to better risk reduction and improved health outcomes.

Clinical Management

The practice doctorate curriculum includes increased credits in the scientific underpinnings for practice. Thus, NPs prepared with a practice doctorate will deliver care based on a deep understanding of genetics, the molecular basis of disease, and pathophysiologic processes. Complex drug selection and dosing will be enhanced through advanced pharmacology and knowl-edge of pharmacogenetics. Clinical management coursework will build from simple to complex health problems. To oversee care of chronically ill patients across the age span, additional emphasis will be placed on preparing NPs who can function as facilitators for patient/family self-management of care. Learning to advise and collaborate with patient/family groups to improve outcomes will be a critical NP skill for the future, supported by specific coursework in interper-sonal communication on the individual, family, and

group levels. Deep integration of mental health content will enable doctorally prepared NPs to address a broader range of psychosocial issues such as commu-nity mental health, post-traumatic stress, interpersonal violence, bipolar disorders, and learning disabilities. Coordination of Care

As environments change, care of patients and fami-lies becomes more complex and commonly involves multiple providers, requiring NPs to act as coordinators of care. Though care coordination across sites and between providers is recognized as a critical skill for future practice,1,2,4,8 the NPs currently moving into this area learn their skills “on the job,” since master’s NP curricula rarely have space to address these skills in any depth. The practice doctorate will prepare NPs to provide leadership beyond direct patient care, equip-ping them with the ability to “see the big picture,” evaluate options, match resources to need, provide clear communication, and exert leadership to create a com-prehensive plan of action and coordinate effective care. Through interprofessional learning experiences and coursework in population-based care, communication, and leadership, the doctorally prepared NP will learn how to improve health outcomes through interdiscipli-nary collaboration and mobilization of a variety of preventive, curative, and rehabilitative resources and interventions for patients and families.

Information and Technology

The practice doctorate curriculum will emphasize skills for nimbly accessing and evaluating information, with students learning to utilize informatics and tech-nology as a foundation for enhanced learning and practice. Seminars in practice management will equip students with the dexterity to appraise new resources. During clinical rotations and residency, the focus will move beyond knowledge acquisition to the application of methods for decision-making and critical appraisal of evidence-based practice. NPs will be prepared to man-age clinical information as a means of informing their practices and providing quality assurance, including utilization of registries and the electronic health record for data collection and analysis. Students interested in informatics will be able to take advantage of additional coursework and the opportunity to conduct a clinical investigation in this area.

Inter-professional Teams

Future projections indicate more care will be deliv-ered through a team approach in order to improve health outcomes.2,4 Interprofessional learning experi-ences during doctoral study will create NPs with skills to form appropriate teams and articulate nursing’s contribution to care while simultaneously recognizing and mobilizing the contributions of other team mem-bers. Many will agree that today’s master’s-prepared

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NP works successfully as a member of an interprofes-sional team and provides leadership, particularly in the area of coordination of care. The doctorally prepared NP will add to this skill base, assuming leadership of the clinical care team itself, working to develop inno-vative strategies that remove barriers and improve access to care. In addition, the doctorally prepared NP will contribute to a wider array of health care teams, such as those that are engaged in clinical research activities (eg, quality assurance or clinical trials) or those that are engaged in developing systems of care delivery. Course work in practice inquiry, policy, and health systems, as well as practice opportunities with multiple disciplines will provide a basis for such lead-ership positions after graduation.

Naturally, questions exist about the impact of this role on other members of the health care team. Current demands for efficiency and quality will no longer tolerate the silo approach to education or care delivery. Collaboration is the mandate for the future, consistent with the Institute of Medicine (IOM) Report, Crossing

the Quality Chasm, which identifies cooperation among

clinicians as a priority for restructuring health care for the 21st century.2 As professional roles are realigned again, some struggle and conflict may be expected. However, the doctorally prepared NP brings increased depth in preparation and, in particular, advanced com-munication and leadership skills to manage this change process effectively. Other colleagues will find working with this new talent results in a higher level of inter-professional collaboration with improved health out-comes.

Clinical Investigation and Leadership

The primary focus of the practice doctorate at the UW is advanced clinical practice with enhanced re-search and leadership skills. While Magyary et al’s article details the research component of the degree6 and leadership issues are highlighted in Brown et al’s,9 the subtle, essential uniqueness of this practice doctor-ate lies in its curricular shift, wherein the leadership component of the curriculum is imbedded throughout coursework and clinical practicum experiences. Lead-ership content is enhanced in existing role and profes-sional issues courses. Additional courses in health care delivery systems, policy analysis, and leadership are required as well. This significant attention to leadership, when combined with improved skills in design and utilization of research, will prompt practice doctorate graduates to be greatly sought-after, and to move more quickly into leadership roles in clinical practice, prac-tice-oriented research, and in policy arenas. Further, by modeling expert care, graduates will “lead by example” in clinical settings, raising the bar for expectations in care quality.

With enhanced skills in clinical research, graduates will also fully participate in quality assurance programs

and clinical outcomes studies, ultimately leading to more effective care practices. At the policy level, graduates will blend their clinical expertise with orga-nizational understanding to develop and evaluate clinic policy, develop practice guidelines, and/or participate on national clinical advisory boards. It is expected that graduates will lead and collaborate in the development of health policies that improve access, ensure compre-hensive quality care, promote prevention, preserve therapeutic relationships, and utilize health care re-sources effectively.

Post-Master’s to Practice Doctorate

Just as practicing certificate-prepared NPs were an important factor in the transition of NPs to master’s level preparation, so, too, current masters-prepared clinicians are critical to the development of the new practice doctorate role. Multiple studies indicate that currently practicing NPs provide accessible, high qual-ity, and effective care.10 –12 With a large component of clinical expertise already in place, this cadre of NPs is poised to quickly advance to doctoral level practice. Although many of these experienced, licensed, and certified NPs will continue to make important contribu-tions via their practice as master’s-prepared clinicians, it is clear that some NPs and NP faculty wish to return for doctoral study in order to pioneer the practice doctorate role. This group is ideally suited to becoming mentors for practice doctorate students, serving as role models for clinical leadership, and taking on faculty roles in the future.

Nationally, the need to develop flexible educational models to assist masters-prepared NPs to obtain the practice doctorate in an efficient manner is heartily recognized.1,8 Facilitating these flexible options for post-master’s study will mean evaluating the individu-al’s educational credentials, practice experience, and professional experience in light of desired competen-cies and standards for doctoral preparation, and then modifying the program of study accordingly. Courses will need to be offered in multiple modalities, at varying times, and with strategic use of Web-based coursework to enable the returning NP to earn the doctoral degree—particularly NP students who must continue some level of practice while completing the practice doctorate requirements.

At the UW, several options are under consideration for post-master’s NP education. One option would allow NPs to obtain doctoral education along with enhanced depth in their current area of certification. Another option would enable NPs to add another focus of study, leading to an alternate area of interest and expertise, and possibly to certification in another spe-cialty area. For example, a Family Nurse Practitioner (FNP) might return to concentrated study and clinical experience in geriatrics and eventually become certified as a geriatric NP. Or, an FNP might remain certified

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only in family practice but enhance his or her practice with focused study in areas such as genetics, informat-ics, nutrition, geriatrinformat-ics, or specific disease states (eg, diabetes, asthma, heart disease, HIV/AIDS). The re-verse may also occur: a Geriatric NP might return for generalist study in the doctoral program and add certi-fication as an FNP. These post-master’s expert clini-cians will be not only an integral part of the develop-ment of the practice doctorate curriculum, but also of the development of the doctorally prepared NP role.

Conclusion

Contemporary societal need and turmoil in the health care system present renewed challenges to nursing. With these challenges comes the opportunity to in-crease nursing’s capacity to provide leadership toward improving the health status of the nation through the initiation of the practice doctorate. Historically, NPs have proven to be cost effective, efficient providers of high quality care. Established NP education has been successful in the past but now must be enriched to meet current and anticipated future challenges. Doctoral preparation that blends the integrative nursing role with enhanced clinical, leadership, and research skills will position NPs to answer many of the needs and chal-lenges facing the health care system. Curricula need to be carefully crafted, incorporating successful elements from the past, letting go of others that have served their usefulness—such as narrowly defined research require-ments—and adding new areas such as those identified above. In addition, careful attention must be given to a full utilization of a wide array of teaching modalities and content delivery. Two distinct partners, education and practice, are simultaneously identifying the practice doctorate as the way to accomplish these goals. Now is the critical time to transform education for advanced practice nursing.

We gratefully acknowledge the University of Washington School of Nursing Practice Doctorate Task Force for their feedback. The PDTF members are listed in alphabetical order: Michele Acker, Marie-Annette Brown, Mary Ann Draye, Diane Magyary, Carole Schroe-der, JoAnne Whitney, Sue Woods and Phyllis Zimmer.

References

1. American Association of Colleges of Nursing. October 2004 AACN position statement on the practice doctorate in nursing. Available at http://www.aacn.nche.edu/DNP/

DNPPositionStatement.htm. Accessed March 7, 2006.

2. Institute of Medicine (IOM). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press; 2001.

3. Future of Family Medicine Project Leadership Committee. The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med 2004;2 (Supp1): S3-32.

4. PEW Commission. Health America: Practitioners for 2005. An agenda for action for US professional schools. 1991, 1999.

5. Brown MA, Draye MA, Zimmer PA, Magyary D, Woods SL, Whitney J, Acker M, Schroeder C. Developing a practice doctorate: University of Washington perspectives and experience. Nursing Outlook 2006;54:130-8.

6. Magyary D, Whitney JD, and Brown MA. Advancing practice inquiry: research foundations of the practice doc-torate in nursing. Nursing Outlook 2006;54:139-151. 7. Hamric A, Spross JA, Hanson CM. Advanced practice

nursing: an integrative approach. 3rd ed. Philadelphia, PA: WB Saunders; 2004.

8. National Organization of Nurse Practitioner Faculties (NONPF) Practice Doctorate Task Force. The Practice Doctorate in nursing: Future or fringe? Topics in Advanced Practice Nursing E–journal 2003;3:2. Available at: http://

www.medscape.com/viewarticle.Accessed May 2, 2005.

9. Brown MA, Kaplan L, and Schroeder C. Negotiating at an equal table: the nursing practice doctorate and health care leadership. Under review.

10. US Congress Office of Technology Assessment. Nurse practitioners, physicians’ assistants, and certified nurse midwives: A policy analysis (Health technology case study 37, ota-hcs-37 [p 5]). Washington DC: US Government printing office; 1986.

11. Mundinger MO, Kane RL, Lenz ER, Totten AM, Tsai WY, Cleary PD, et al. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. JAMA 2000;283:59-68.

12. Mundinger MO. Who’s who in nursing: bringing clarity to the doctor of nursing practice. Nurs Outlook 2005;53: 173-6.

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