Posted: April 25th, 2025

develop on a word document

The applicant should read the two proposed articles. After reading both articles, the applicant will reflect on the role of a DNP-prepared nurse in the healthcare system and answer the following questions:

1. Why is there a need for DNP-prepared nurses in the current healthcare system?

2. How do you anticipate that a degree in Doctor of Nursing Practice Healthcare Administration will impact your career?

3. Based on the proposed articles, provide a few examples on how you will be able to translate in action the knowledge gained in the DNP in your current workplace or work field? 

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2

Title That Fits on One Line

Your Name

Miami Regional University

DNP Entrance Essay

Date of Submission

DNP Entrance Essay

Intro here…

Need for DNP-Prepared Nurses in the Current Healthcare System

Paragraph here…

Impact of the DNP Degree on your Career

Paragraph here…

Few Examples on Translation of Knowledge Acquired from DNP in the Current Workplace

Paragraph here…

References

Grace, Pamela, PhD, R.N., F.A.A.N. (2018). Enhancing Nurse Moral Agency: The Leadership Promise of Doctor of Nursing Practice Preparation.
 Online Journal of Issues in Nursing, 23(1), 1-11.

Moore, K. S., & Hart, A. M. (2021). Critical juncture: The doctor of nursing practice and COVID-19. 
Journal of the American Association of Nurse Practitioners, 
33(2), 97-99.

Essay Instructions

DNP Entrance Requirement

The applicant should read the two proposed articles. After reading both articles, the applicant will reflect on the role of a DNP-prepared nurse in the healthcare system and answer the following questions:

1. Why is there a need for DNP-prepared nurses in the current healthcare system?

2. How do you anticipate that a degree in Doctor of Nursing Practice Healthcare Administration will impact your career?

3. Based on the proposed articles, provide a few examples on how you will be able to translate in action the knowledge gained in the DNP in your current workplace or work field?

Time limit

60 minutes allocated to read the articles.

120 minutes to write the essay

The applicant has a total of up to three hours to complete the task.

The Essay shall

Elaborate on all three questions, use APA format, and should not exceed 1500 words and have a minimum of 1000 words. Please cite the proposed articles in your work.

Template

A template will be provided to write the essay as the DNP faculty believe in providing tools for the students to succeed. Thus, each course in the MRU DNP program encompasses template for each expected assignment.

Articles Proposed

Grace, Pamela, PhD, R.N., F.A.A.N. (2018). Enhancing Nurse Moral Agency: The Leadership Promise of Doctor of Nursing Practice Preparation.
 Online Journal of Issues in Nursing, 23(1), 1-11.

Moore, K. S., & Hart, A. M. (2021). Critical juncture: The doctor of nursing practice and COVID-19. 
Journal of the American Association of Nurse Practitioners, 
33(2), 97-99.

image1

Clinical Scholars Review, Volume 8, Number 1, 2015 © Springer Publishing Company 13
http://dx.doi.org/10.1891/1939-2095.8.1.13

DNP/ARNPs AND ComPReheNsive CARe: ADvANCiNg CliNiCAl PRACtiCe

The Necessity of the Doctor
of Nursing Practice in

Comprehensive Care for
Future Health Care

Michael A. Carter, DNSc, DNP, DCC
University of Tennessee Health Science Center

Phillip J. Moore, MSN, FNP-BC
University of Tennessee, Knoxville

The education of nurse practitioners has undergone substantial evolution since Ford and Silver
(1967) first reported on the preparation of nurses to assume the role of primary care providers for
children. From this modest beginning in Colorado emerged a worldwide movement to prepare
nurses to diagnose and treat patients in ways that in the past had been restricted to physicians. The
early programs were not usually located in schools or colleges of nursing but rather were short-term
continuing education programs. Later, nurse practitioner programs were transitioned to master’s
degree programs and more recently began to evolve to Doctor of Nursing Practice (DNP) Pro-
grams. The American Association of Colleges of Nursing (2014) currently lists 243 active DNP
programs and 70 planned programs.

This article examines the historical context for the de-
velopment of the Doctor of Nursing Practice (DNP) in
comprehensive care. In doing so, there is a consideration
of the substantial social and political issues in play dur-
ing this evolution. Also covered are the emerging health
care issues that mandate a higher level of practice prepa-
ration and certification for nurse practitioners who will
assume independent practices in the future.

Historical Background of the Doctor of Nursing
Practice in Comprehensive Care

Nursing education in the United States has undergone
almost constant evolution since the latter part of the
19th century when programs began in hospitals. Pro-
grams began a very slow move into American universi-
ties in the 1950s, and by the mid-1960s, new programs

emerged to prepare a new product, the nurse practitioner
(Ford & Silver, 1967). The creation of nurse practitio-
ner programs followed the earlier introduction of pro-
grams to prepare nurse anesthetists, nurse midwives,
and clinical nurse specialists. The emergence of nurse
practitioner programs is interesting in that these pro-
grams violated the definition of nursing adopted by the
American Nurses Association in 1955. Part of that defi-
nition was that nursing specifically did not include acts
of diagnosis or prescription of therapeutic or corrective
measures (American Nurses Association [ANA], 1955).
These early nurse practitioner programs were designed
specifically to prepare registered nurses to diagnose
and treat patients who presented in a primary care set-
ting; treatment entailed prescriptions of drugs as well as
other therapeutic and corrective measures (Cockerham
& Keeling, 2014).

14 Carter and Moore

of Nursing (AACN) that called for all advanced prac-
tice nursing education to transition to the DNP level by
2015. This rapid proliferation of programs created new
issues. Few of the programs, beyond the initial ones,
were focused on nurse practitioner education. Almost
all of the new programs were postmaster’s programs and
did not include much, if any, of the supervised clini-
cal experience needed to prepare nurse practitioners to
provide comprehensive care for patients across various
settings. Instead, they added additional general core
courses in health policy, economics, epidemiology, and
quality improvement. Also, DNP programs focused in
health policy, nursing informatics, nursing administra-
tion, and similar areas opened that did not have direct
care as a focus. At the time of this writing, there are
243 active DNP programs and 70 planned programs
listed by the AACN (2014).

Development of Competencies and Certification

In the summer of 2000, the Council for the Advance-
ment of Comprehensive Care (CACC) representing
the three schools with developing DNP programs;
other invited schools with similar interests; and key
stake holders in nursing, medicine, and industry held its
first international meeting to attempt to reach consen-
sus about the standards for practice at the DNP level
(CACC, n.d.). The specific focus was how to distin-
guish DNP graduates prepared in comprehensive care,
from DNP graduates prepared in other specialties. The
CACC concluded that there was a need to distinguish
DNP graduates who were prepared and could dem-
onstrate competency to practice comprehensive care
(Carter, 2013). The American Board of Comprehen-
sive Care (n.d.) was created by the CACC in 2007 as
an independent organization whose purpose would be
to develop a certification program for qualified DNP
graduates who met this new, higher standard of care
delivery. The certification program was accredited by
the National Commission for Certifying Agencies in
November 2011 (Carter, 2012).

The process of developing a certification examina-
tion in comprehensive care required that specific com-
petencies be elucidated. The Institute of Credentialing
Excellence (2005) identifies two methods for identify-
ing clinical competencies for health care practitioners.
These are an incumbent job analysis study or logical
job analysis. Developing the certification for the DNP
in comprehensive care posed a challenge in that there
were few DNPs with a practice in comprehensive care

Over the next 35 years, nurse practitioner educa-
tion evolved from short-term certificate programs to
master’s and postmaster’s programs. This evolution con-
tinued as state laws began to require master’s level edu-
cation for new graduates who wished to be authorized
to prescribe medications and bill for services. Almost
from the inception of the new master’s programs was
the concern by nursing faculty and the profession that
the length and depth of these programs was not suf-
ficient for the level of the work expected of the new
graduates (Cockerham & Keeling, 2014).

The idea of offering a doctoral degree for nurses had
been around for quite a while. The profession had a his-
tory of offering research doctoral degrees that began in
the 1920s, but there was a rapid growth of these doctoral
programs that occurred around the time that nurse prac-
titioners’ education was moving into master’s degree pro-
grams (Carter, 2006). The first clinical doctoral program,
the Doctor of Nursing (ND), began at the Frances Payne
Bolton School of Nursing at Case Western Reserve
University in 1979 (Standing & Kramer, 2003). Three
additional ND programs opened over the next few years
(Hathaway, Jacob, Stegbauer, Thompson, & Graff, 2006).
Nursing continued to evolve and respond to changes and
demands of health care trends. The late 20th and begin-
ning of the 21st centuries saw the development of the
first work that led to the opening of the first Doctor of
Nursing Practice (DNP) programs by three schools: the
University of Tennessee Health Science Center in 1999,
the University of Kentucky in 2001, and Columbia Uni-
versity in 2005 (Hathaway, et al., 2006). The goal of these
programs was to craft a clinical doctoral program for ad-
vanced practice nurses who would be prepared for a level
of practice that had not been previously seen.

The driving force for the creation of these programs at
the University of Tennessee Health Science Center and
Columbia University emerged from the sophisticated
faculty practices of these schools. The faculty in nursing
were engaged in practices that mirrored the other health
sciences. In these practices, the nursing faculty were in-
dependently diagnosing and treating patients, caring for
patients across sites, billing for services, educating stu-
dents, and conducting clinical research. These programs
learned that the traditional master’s programs they had
been offering were not sufficient in rigor or focus to pre-
pare graduates for independent practice across sites in an
evolving health care system (Hathaway et al., 2006).

From these early beginnings, DNP programs began
opening rapidly, particularly following the 2004 posi-
tion statement by the American Association of College

DNP in Comprehensive Care 15

systems, aggregate models of care for the management
of chronic illness, and continuous monitoring of qual-
ity of care delivered and improvements where needed
(Rittenhouse, Shortell, & Fisher, 2009).

In the past, master’s level nurse practitioners were
prepared to deliver care in a private office or clinic
setting. Some of the most complex and challenging as-
pects of health care, including medication errors and
errors in communication, occur when patients transi-
tion from home to hospital; from hospital to subacute
care setting, such as rehabilitation centers or nursing
homes; from subacute settings to home; or to palliative
care (Forster, Murff, Peterson, Gandhi, & Bates, 2003).
Historically, nurse practitioners did not receive the
preparation to provide care across multiple health care
sites, yet this is now required to reduce morbidity and
mortality. Current clinical information systems do not
share across these settings, even though there are new
incentives being developed by the Centers for Medicare
and Medicaid Services (2014), to attempt to deal with
this problem. What is required of nurse practitioners,
however, is that they must be competent to understand
the systems of care in the various settings in which care
is delivered and the ways in which patients are treated
in these sites of care. Nurse practitioners who are pre-
pared in comprehensive care have these competencies,
which are not part of other nurse practitioner educa-
tion programs (Thomas et al., 2012), because these
competencies are built into the DNP programs in com-
prehensive care and tested on the American Board of
Comprehensive Care.

The ACA is opening the doors to care for millions
of Americans who did not previously have access to care
because they were uninsured or underinsured. The White
House (2014) reports that about 20 million people have
insurance today that did not have insurance last year
under the previous system; this insurance coverage in-
cludes at a minimum primary care, specialist care, hos-
pital care, and preventive care. Nurse practitioners will
provide care to many of the millions of new enrollees.

Evidence exists that there will be substantial new
demands for care from these newly insured individuals.
In 2006, Massachusetts began their move to provide
insurance coverage for all the people of the state and
the Massachusetts’ insurance program shares many
of the key components of the ACA (Henry J. Kaiser
Family Foundation, 2012). This experience by Massa-
chusetts can serve as an indicator as to what the rest
of the country might expect with full implementation
of the ACA. The Henry J. Kaiser Family Foundation

to support an incumbent job analysis. There was other
work, however, that could assist with the logical job
analysis. The AACN (2006) had released its document
entitled The Essentials of Doctoral Education for Advanced
Nursing Practice in 2006, the same year the National
Organization of Nurse Practitioner Faculties (NONPF,
2006) released their competencies for the DNP. These
documents, combined with the work of the CACC,
formed the basis for the logical job analysis.

Designing a national certification examination
with appropriate psychometrics is a very complex un-
dertaking. The National Board of Medical Examiners
(NBME), an organization with a long history in devel-
oping such examinations for health care professionals,
entered into a contract with the American Board of
Comprehensive Care to design and administer the com-
prehensive care examination and to use the logical job
analysis as the basis of the examination (National Board
of Medical Examiners [NBME], n.d). The purpose of
the examination was to “assess the knowledge and skills
necessary for nurse clinicians to provide safe and ef-
fective patient-centered comprehensive care” (NBME,
n.d., p. 2). The first examination was administered in
2008 (Carter, 2012).

By 2011, a cohort of DNPs had graduated, were
certified, and agreed to participate in the first incum-
bent job analysis study of DNPs in comprehensive care
(Honig, Smolowitz, & Smaldone, 2011). This job analy-
sis confirmed the competencies identified by the logical
job analysis that had been performed earlier by the ex-
perts for the American Board of Comprehensive Care.

Emerging Health Care Trends Requiring Different
Nurse Practitioners

There are several changes taking place in the health care
system of the United States which call for additional
preparation for future nurse practitioners. The Patient
Protection and Affordable Care Act, commonly short-
ened to the Affordable Care Act (ACA; U.S. Congress,
2010), is changing the way primary care is delivered, in-
cluding the creation of patient-centered medical homes.
This model of care is designed to improve the quality
of primary care delivered in the United States and at
a lower cost. The critical element of first-contact for
care remains in the patient-centered medical homes,
but there are new requirements that the care be con-
tinuous, comprehensive, and coordinated across the care
continuum (U.S. Congress, 2010). The promise is that
this care will make use of new electronic information

16 Carter and Moore

help bring some logical order to conflicting plans of care
by different groups and to work to bring about the desired
end of life including palliative care when needed. Previous
educational programs for nurse practitioners just did not
provide this expertise. These are the competencies of the
DNP who is prepared in comprehensive care.

Conclusion

The health care system of the United States is experi-
encing several dramatic changes in the way care is de-
livered, and nurses will play a major role in bringing
about these changes. What is likely to occur is increased
demand for primary care but not the primary care of
the past. Clearly there will remain the requirements of
first-contact for care by a professional who will likely
work in teams of care. But no longer can this care be
built on discrete episodes of care. In the future, this care
will be required to be continuous across episodes, pro-
vide comprehensive services including new emphasis on
health promotion and disease prevention, and be highly
coordinated across the care continuum. To do less fails
to provide the expected quality of care and places the
patient in potential harm.

Nurse practitioners have long proven their expertise
in delivering primary care services to a variety of patient
populations in many geographic regions. These past suc-
cesses have been well documented but will not be suffi-
cient for the emerging health care system. Also, the pre-
vious models of nurse practitioner education will not be
sufficient. New medical advances will bring challenges
in helping patients navigate systems and modalities of
care that are much different than what is seen today.
As options and choices in care expand, so too expands
the need for nurse practitioners who can help select the
best options and make the best choices for the individ-
ual patient. Only the diplomates in comprehensive care
have the documented knowledge, skills, and abilities to
be the guide to care that is demanded now and will be
in even greater demand in the future.

Harm to patients through medical errors, lack of
communication, and poor judgment by clinicians should
be avoided at all cost. These potentially fatal errors can
be avoided by nurse practitioners who possess the re-
quired competencies that are a part of the DNP in com-
prehensive care. With the cadre of exquisite clinicians
that are being prepared and certified to provide com-
prehensive care, nurse practitioners will lead the way in
a reformed health care system.

(2012) indicated that by 2010, Massachusetts reported
6.3% of the population was uninsured compared to
18.4% for the rest of the United States. The people of
Massachusetts are more likely to have a usual source of
care other than the hospital emergency room and are
more likely to have had a preventive care visit in the
last year compared the rest of the United States (Henry
J. Kaiser Family Foundation, 2012). In addition, there
were substantial declines in all-cause mortality and
mortality from causes amenable to health care following
the implementation of the near universal coverage in
Massachusetts (Sommers, Long, & Baicker, 2014). One
of the most dangerous times for patients is the transi-
tion from one site of care to another (Naylor, Aiken,
Kurtzman, Olds, & Hirschman, 2011). These transitions
are where the largest amount of morbidity and mortal-
ity occur. The emerging new demands for care from a
reformed health care system call for DNP nurse prac-
titioners to be educated in new models of comprehen-
sive care to assure that the lessons from the past will be
shared with the rest of the nation.

Along with a reformed structure for payment, the
American health care system is beginning to under-
stand the many challenges posed by an aging popula-
tion. There were more than 43 million older Americans
in 2012, and this is expected to grow to 56 million by
2020 (U.S. Department of Health and Human Ser-
vices, 2013). The Agency on Aging (U.S. Department
of Health and Human Services, 2013) provides some
sobering statistics: Only 42% of older Americans report
their health to be excellent or very good, and most have
at least one chronic condition with many having sev-
eral. The most common conditions experienced by older
Americans include hypertension (72%), arthritis (50%),
heart disease (30%), cancer (24%), and diabetes (20%)
and often more than one condition can exist at the
same time for the same patient. These health problems
illustrate the level of care required for this age group
compared to younger age groups. Americans older than
75 years of age are substantial users of care with 23%
visiting their primary care practitioner or specialist on
average of 10 or more times per year, and the rate of hos-
pitalization for Americans older than 65 years is three
times that of younger Americans (U.S. Department of
Health and Human Services, 2013).

Nurse practitioners of the future will need enhanced
skills and knowledge of how to help these older Americans
navigate the multiple sites of care and myriad of diverse
providers and specialists. Nurse practitioners are poised to

DNP in Comprehensive Care 17

Honig, J., Smolowitz, J., & Smaldone, A. (2011). APRN
survey on roles, functions, and competencies. Clinical
Scholars Review, 4(1), 15–19.

Institute of Credentialing Excellence. (2005). National Commis-
sion for Certifying Agencies (NCCA) standards. Retrieved from
http://www.credentialingexcellence.org/p/cm/ld/fid=66

National Board of Medical Examiners. (n.d.). NBME deve-
lopment of a certifying examination for doctors of nursing
practice. Retrieved from http://www.nbme.org/pdf/nbme-
development-of-dnp-cert-exam

National Organization of Nurse Practitioner Faculties. (2006).
Practice doctorate nurse practitioner entry-level competencies
2006. Retrieved from http://c.ymcdn.com/sites/www.nonpf
.org/resource/resmgr/competencies/dnp%20np%20
competenciesapril2006

Naylor, M. D., Aiken, L. H., Kurtzman, E. T., Olds, D. M., &
Hirschman, K. B. (2011). The care span: The importance
of transitional care in achieving health reform. Health
Affairs, 30(4), 746–754.

Rittenhouse, D., Shortell, S., & Fisher, E. (2009). Primary
care and accountable care—Two essential elements of
delivery-system reform. New England Journal of Medicine,
36, 2301–2303.

Sommers, B., Long, S., & Baicker, K. (2014). Changes in
mortality after Massachusetts health care reform: A
quasi-experimental study. Annals of Internal Medicine,
160, 585–593.

Standing, T. S., & Kramer, F. M. (2003). The ND: Preparing
nurses for clinical and educational leadership. Reflections
on Nursing Leadership, 29(4), 35–37, 44.

The White House. (2014). Fact sheet: Affordable care act by the
numbers. Retrieved from http://www.whitehouse.gov/
the-press-office/2014/04/17/fact-sheet-affordable-care-
act-numbers

Thomas, A. C., Crabtree, M. K., Delaney, K. R., Dumas,
M. A., Kleinpell, R., Logsdon, M. C., . . . Nativio, D.
G. (2012). Nurse practitioner core competencies. Retrieved
from http://c.ymcdn.com/sites/www.nonpf.org/resource/
resmgr/competencies/npcorecompetenciesfinal2012

U.S. Congress. (2010). Patient Protection and Affordable Care
Act. Retrieved from http://www.govtrack.us/congress/
bills/111/hr3590/text

U.S. Department of Health and Human Services. (2013).
A profile of older Americans: 2013. Retrieved from http://
www.aoa.gov/Aging_Statistics/Profile/index.aspx

Correspondence regarding this article should be directed to
Michael A. Carter, DNSc, DNP, DCC, University of Tennessee
Health Science Center, Memphis, TN 38163. E-mail: mcarter@
uthsc.edu

References

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position statement on the practice doctorate in nursing.
Retrieved from http://www.aacn.nche.edu/publications/
position/DNPpositionstatement

American Association of Colleges of Nursing. (2006). The
essentials of doctoral education for advanced nursing practice.
Retrieved from http://www.aacn.nche.edu/publications/
position/DNPEssentials

American Association of College of Nursing. (2014). Doctor
of nursing practice. Retrieved from http://www.aacn.nche
.edu/dnp/about/talking-points

American Board of Comprehensive Care. (n.d.). Mission and
goal statement. Retrieved from http://nursing.columbia
.edu/dnpcert/abccmission.shtml

American Nurses Association. (1955). ANA board appro-
ves a definition of nursing practice. American Journal of
Nursing, 5, 1474.

Carter, M. (2006). The evolution of doctoral education
in nursing. In C. Bridges, A. Lowenstein, L. Andrist,
P. Nicholas, & K .Wolf (Eds.), History of nursing ideas
(pp. 383–391), New York, NY: Jones & Bartlett.

Carter, M. (2012). Educating nurses for the highest level of
practice. Clinical Scholars Review, 5(1), 4–5.

Carter, M. (2013). Certifying competency in comprehensive
care. Clinical Scholars Review, 6(2), 87–88.

Centers for Medicare and Medicaid Services. (2014). 2014
definition stage 1 of meaningful use. Retrieved from http://
www.cms.gov/Regulations-and-Guidance/Legislation/
EHRIncentivePrograms/Meaningful_Use.html

Cockerham, A., & Keeling, A. (2014). A brief history of advan-
ced practice nursing in the United States. In A. Hamric,
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practice nursing: An integrative approach (pp. 1–26). St.
Louis, MO: Elsevier.

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History. Retrieved from http://nursing.columbia.edu/
caccnet/history.shtml

Ford, L., & Silver, H. (1967). The expanded role of the nurse
in child care. Nursing Outlook, 15, 43–45.

Forster, A., Murff, H., Peterson, J., Gandhi, T., & Bates, D.
(2003). The incidence and severity of adverse events affec-
ting patients after discharge from the hospital. Annals of
Internal Medicine, 138, 161–167.

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familyfoundation.files.wordpress.com/2013/01/8311

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Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.

Enhancing Nurse Moral Agency: The
Leadership Promise of Doctor of
Nursing Practice Preparation

^ m d

Abstract

…it is more critical
than ever that we
remain mindful
about the demands
of ‘good’ patient
care.

The development
of knowledgeable
and skillful nurse
leaders is
necessary to
enhance
interdisciplinary

Pamela Grace, PhD, RN, FAAN

An expansive and growing body of literature documents the problem of nurses’ moral distress when
they are unable to carry out actions that they perceive to be in the best interests of patients.
Further, nurse leaders and educators are not always well prepared to help nurses to develop moral
agency. Moral agency is the ability to provide good care and overcome obstacles to good practice.
One reason for the lack of preparation is that ethics education in academia, and in ongoing nurse
education, has been inconsistent or has focused more on dilemmas than the ubiquitous everyday
practice issues. The purpose of this article is to discuss goals of the nursing profession,
contemporary challenges to good nursing practice, and leadership from those educated as Doctors
of Nursing Practice (DNP). The author argues that the proliferation of (DNP) programs, focused as
they are on leadership in practice settings, presents a unique opportunity to prepare nurse leaders
who are, first and foremost, skilled and knowledgeable about the ethical content of everyday
nursing practice. An ‘ethics matrix’ is described and proposed as an essential base for DNP
education upon which all other knowledge is built, with specific discussion of types of leadership and
the relationship of transformational learning to transformational leadership.

Citation: Grace, P., (January 31, 2018) “Enhancing Nurse Moral Agency: The Leadership Promise of Doctor of
Nursing Practice Preparation” OJIN: The Online Journal of Issues in Nursing Vol. 23, No. 1, Manuscript 4.

DOI: 10.3912/OJIN.Vol23No01Man04

May I stress the need for courageous, intelligent, and dedicated leadership … leaders of sound integrity. Leaders
not in love with publicity, but in love with justice. Leaders not in love with money, but in love with humanity.
Leaders who can subject their particular egos to the greatness of the cause. (Dr. Martin Luther King, Jr. Challenge
of the new age (speech on the Prayer Pilgrimage for Freedom in Washington, DC, May 17, 1956).

Dr. King’s plea was for leadership during a troubling era. He hoped to change
prevailing societal attitudes toward African American citizens of the United States
(U.S.). His words remain cogent today for other settings where social justice and
human dignity are at risk. For healthcare professionals, it is more critical than
ever that we remain mindful about the demands of ‘good’ patient care. So many
pressures exist (e.g., financial, political), and it can be expedient to neglect or
even abandon professional goals and responsibilities (Bultas, Ruebling, Breitbach,
& Carlson, 2016).

Additionally, nursing leaders both in academic and clinical settings must often walk
a tightrope between the economic or reputational/visibility demands of the
institution or school, and upholding professional goals (Gaylord & Grace, 2018;
Jacob, 2009; Lown, 2007). All of these factors add to the urgency of developing
nurse leaders who have the knowledge and skills to educate and support point-of-
care nurses in their work and their ability to advocate for good patient care at
whichever level is required: immediate, institutional, or even policy. Skills of
communication and collaboration are also important. The development of

collaborations for
quality, safe patient
care.

Goals of the Nursing Profession

Nursing goals serve
as the main
anchors for
understanding our
ethical
responsibilities…

These three
domains form an
ethical matrix upon
which to build
other essential
knowledge and
skills for advanced
nursing practice
and leadership.

…it is important to
confirm the DNP
role as one of
ethical

knowledgeable and skillful nurse leaders is necessary to enhance interdisciplinary
collaborations for quality, safe patient care.

The purpose of this article is to present an argument that doctor of nursing practice (DNP) graduates focused, as
they ostensibly are, on developing the expertise for good practice, should first and foremost be prepared for
ethical leadership. As noted in the American Association of Colleges of Nursing’s (AACN) document, The Essentials
of Doctoral Education for Advanced Nursing Practice (2006), promulgating the DNP degree was important for
several reasons. Among the reasons was that “expansion of scientific knowledge [is] required for safe nursing
practice [amid] growing concerns regarding the quality of patient care delivery and outcomes. Practice demands
associated with an increasingly complex health care system created a mandate for reassessing the education for
clinical practice for all health professionals, including nurses” (p.4). Logically then, DNP curricula must be firmly
rooted in disciplinary knowledge; an understanding of responsibilities of the nursing profession to individuals and
society; and a grasp of the role of interdisciplinary collaboration in achieving quality healthcare.

The education of DNPs is an ethical undertaking because advanced nursing practice is no less about facilitating
human health and well-being than are other nursing degrees. All subsequent specialty knowledge and skills
needed for advanced practice should be built upon professional goals and from the unifying perspective of nursing
as developed over time. The historically developed, central unifying focus of nursing has been articulated as
“facilitating humanization, meaning, choice, quality of life, and healing in living and dying” (Willis, Grace, & Roy,
2008, p. E28). Further, I propose that DNPs can, and ought to, be developed as transformational leaders.
Transformational leadership is the ability to empower and motivate others toward a common vision or common
goals, as explained shortly (Gaylord & Grace, 2018).

Ethical aims of nurses to provide humane, quality nursing care anchored in the goals and mandates of our
profession should be front and center for all our initiatives including, and most importantly, the development of
nurse educators and leaders (American Nurses Association [ANA], 2010; ANA 2015; Willis et al., 2008). As a
reminder, these goals are “the protection, promotion and restoration of health and well-being; the prevention of
illness and injury; and the alleviation of suffering” (ANA, 2015, p. vii). The types of influences that can distract us
from maintaining a focus on ethical care are well documented in the literature and seem to be increasing despite
the Institute of Medicine report (2010) outlining the nursing role in assuring quality care goals (Jurchak et al.,
2017; Liaschenko & Peter, 2016; Miller, 2006; Starr, 2011).

Nursing goals (ANA 2010; ANA 2015; International Council of Nursing, 2012)
serve as the main anchors for understanding our ethical responsibilities and
constitute the connecting fibers of what could be called an ‘ethics matrix.’
However, understanding ethical responsibilities, while necessary, is insufficient for
good practice. Knowledge of ethics ‘language’ and skills is also critical. A grasp of
the nuances of ethical principles and their relationship to ethical decision-making
and moral agency (i.e., acting for the good) are also important as they provide a
common language for team decisions. A third essential facet is the development of
personal characteristics that motivate one to take action and persevere to
complete needed actions.

These three domains form an ethical matrix upon which to build other essential
knowledge and skills for advanced nursing practice and leadership. An additional
slate of knowledge and skills deemed essential for advanced practice nursing
across settings is outlined in the AACN (2006) DNP ‘Essentials’ document. These
more specialized knowledge and skills, such as “Scientific Underpinnings for
Practice” (Essential I) and “Organizational and Systems Leadership…” (Essential
II), along with the other essentials, should be firmly rooted in and emanate from
the three-domain ethical matrix to provide cohesion among them. To state this
another way, the Doctor of Nursing Practice degree is first and foremost a nursing
degree predicated on furthering nursing goals.

Those responsible for informing, revising, and/or developing national program and
accreditation standards should consider building curricula essentials upon this
ethical matrix as an integrating force. It is critical that emergent DNP leaders in
the discipline are equipped with the knowledge, skills, and motivation to transform
nursing practice and be instrumental in the development of ethically aware,
motivated nurses. As DNP programs continue to proliferate, it is important to

Being mindful of
limited resources
and justice in the
allocation of them
is also an ethical
issue.

transformative
leadership…

Contemporary Challenges to Good Nursing Practice

…[business]
principles can
sometimes collide
with human-
centered goals of
quality patient
healthcare.

The Promise of DNP Leadership

confirm the DNP role as one of ethical transformative leadership regardless of
specialty practice area.

Challenges posed by contemporary nursing practice environments require pro-
active, transformative leaders who can facilitate nurses’ confidence in their ability
to act for patients at the bedside, in the community, and in influencing policy
making (Gaylord & Grace, 2018). There are knotty tensions between the need for
cost-containment and profits in the U.S. healthcare system, and the reasons that
healthcare professions and institutions exist. Stated another way, healthcare
institutions, both inpatient and outpatient, exist because people have a critical
need for them to assist in addressing a broad array of possible healthcare needs,
not solely physical illness. The central unifying focus and nursing goals provide the
broad perspective of nursing related to a focus on health and well-being that
extends beyond illness.

When the provision of healthcare becomes primarily a business, corporate goals of profits can overpower human
service goals, straining clinicians’ ability to primarily focus on patients and their needs (Mechanic, 2006;
Rosenthal, 2017; Starr, 2011). Therefore, persons with unmet healthcare needs depend on professionals and
institutions that expressly exist to fulfil these needs to actually so do.

The current situation in the U.S. is that a substantial portion of healthcare is
susceptible to business principles and these principles can sometimes collide with
human-centered goals of quality patient healthcare. This is not the same as saying
that cost-effectiveness in healthcare is unimportant; it is of course a very
important consideration. Being mindful of limited resources and justice in the
allocation of them is also an ethical issue. Even countries without a profit incentive
in the provision of healthcare have to ensure cost-effectiveness as a social justice
issue, as discussed in detail elsewhere (Grace, 2018; Johnson & Stoskopf, 2010).
However, the United States, it has been argued, does not have an integrated
healthcare ‘system;’ we do not have an overarching organizing structure for
healthcare delivery from cradle-to-grave or from promoting and maintaining

health to acute and chronic illness care. This situation in the United States complicates the task of healthcare
professionals to further goals of good healthcare for individuals and society (Chaufan, 2015; Elhauge, 2010;
Powers & Faden, 2006). What nursing can do as a profession is to highlight and try to remedy injustices that
interfere with people living a ‘minimally decent life’ by informing and influencing policy at the individual level, and
advocating for good patient care (Grace & Willis, 2008; Powers & Faden, 2006).

Recent moves to make a DNP degree the entry level education for advanced practice nursing, despite ongoing
critiques, seem unstoppable at this point (Dracup, Crononwett, Melies, & Benner, 2005; Martsolf, Auerbach, Spetz,
Pearson, & Muchow, 2015; McLeod-Sordjan, 2014; Miller, 2008). A positive aspect of this change in advanced
practice preparation, with its emphasis on leadership, is the promise the movement holds for good (i.e., ethical)
patient care and remediation of injustices for disadvantaged populations (as related to receiving quality
healthcare, including primary care). Specifically, transformational leadership skills and characteristics are needed
(Gaylord & Grace, 2018; Marshall & Broome; 2016).

Coherent and comprehensive preparation for doctoral (i.e., DNP) level practice requires both a rigorous curriculum
that prepares leaders who understand the nature of their role as embedded within the profession and its goals,
and essential ingredients (i.e., knowledge and skills) for leading others. Fundamental to this preparation is, as
noted earlier, an education rooted in an ethics matrix.

Another way to view this idea of building ethical competence is to consider Rest’s (1982) four cognitive processes
that give rise to moral agency. From an extensive review of interdisciplinary literature including that of the
cognitive sciences, Rest, a cognitive psychologist, theorized four non-hierarchical, iterative, and interrelated
processes that take place in the mind of a person engaged in moral decision-making with an intent to act
(implying both cognitive and affective components). These processes are developmental in nature and can be
cultivated. Described in numerical order below for discussion purposes, they are interactive processes and not
linear in nature.

First, Rest purports that there is an ‘interpretation of the situation’ that includes ethical aspects (moral sensitivity).
Second, the person draws on prior knowledge to make sense of the situation and decide what should be done
(moral reasoning). Third, a decision is made among competing actions to determine which is the likely best action
given knowledge of the situation (motivation). Finally, one envisions the steps to take and obstacles to overcome

A ‘Wake Up’ Call for the Profession of Nursing

Building these skills
should be an
imperative of the
ethics of the
profession.

A unifying core
understanding of
responsibilities of
the profession
coupled with
fluency in ethics
language and
techniques can
provide context,
stability, and
coherency…

Rooting All Curricula in an Ethics Matrix: An Ethical Imperative

Expedient actions
are those based on
convenience,
efficiency, personal
ease, or fear of

(moral character) (Grace, 2018; Rest & Narvaez, 1993; Rest, 1982; 1983). Given the preparation that advances or
refines a DNP’s capacity to engage in moral agency, development of a large cohort of ethically aware and skilled
leaders is possible. This cohort can in turn serve to develop the ethical confidence of students, point-of-care
nurses, colleagues, and allied professionals.

If the doctor of nursing practice role is significantly one of leadership, then DNPs must understand the unique
nature of their discipline and how nursing goals and perspectives are both separate from, but overlapping with, the
goals of allied health professions. All healthcare professionals (self-evidently) share ultimate goals to improve the
health of individuals and society, but they do so through the different lenses of their professions, and profession-
specific aims. At times, these goals coalesce and require the pertinent professions to seek collaborative input to
move an objective forward.

The essential set of characteristics, knowledge, and skills needed for DNP ethical
leadership is captured both by Rest’s (1982) processes and the previously
discussed ethics matrix, which is informed by Rest’s work. It is critical to base the
development of leadership skills in nursing goals and perspectives and attendant
obligations, the demands of ethical practice, and the motivation to act to improve
practice. This set of knowledge and skills should serve as the basis from which
other essential knowledge, as outlined in the AACN (2006) ‘Essentials’ document,
is built. Building these skills should be an imperative of the ethics of the
profession.

There are two senses of nursing ethics discernable in the literature. In the first sense, nursing ethics is the field of
inquiry that seeks to define such things as good nursing care; the characteristics of good nurses; and how nurses
should act, to name a few. This process of inquiry draws on moral philosophy and its’ derivative, professional
ethics, and includes tools of analysis and synthesis. From nursing ethics, in this sense, we have developed codes
of ethics. In the second sense, nursing ethics is about evaluation of nurses’ actions related to whether or not they
are intentionally focused on meeting the historically developed goals of the nursing profession, as articulated
earlier.

As a simple example, we can ask whether a nurse is intentionally focused on trying to provide a good for or limit
harms to a delirious patient in restraining him, or is he or she restraining the patient because it is the most
expedient action (Grace, 2009). Ethics in this sense is the capacity and intent to further the goals of the profession
and relies on both an understanding of the nature of the services nursing provides and responsibilities to provide
these services in spite of obstacles. Thus, development of DNPs as ethics leaders necessarily includes both the
nurturing and fortification of personal characteristics and predispositions (sometimes referred to as virtues) and a
certain level of fluency in ethics language and associated skills (e.g., situation analysis, mediation, collaboration).

A unifying core understanding of responsibilities of the profession coupled with
fluency in ethics language and techniques can provide context, stability, and
coherency for curricula, educational programs, and the support of point-of-care
nurses. An underlying ethics matrix in which all other essential domains of content
knowledge are rooted is critical (AACN, 2006). Together, the proposed unifying
ethics matrix, insights from Rest’s (1982) processes of moral action, and the
essential content domains and competencies of DNP programs (AACN, 2006)
provide a strong basis for the development of transformational leaders and
educators; those who can serve as ethics resources and build ethical decision-
making and moral agency skills of students, peers, and allied professionals.

All nurses’ actions are subject to appraisal based on the extent to which they align with nursing goals and
perspectives, or not. We are responsible for furthering the best interests of patients and for working toward a
healthy society (ANA, 2010; ANA, 2015; Grace, 2001; 2009; Grace and Milliken, 2016). Thus, actions based on
expediency or other adverse influences that divert us from the goal of patient interests are problematic.

Expedient actions are those based on convenience, efficiency, personal ease, or
fear of censure rather than reactions to patient needs and concerns. For example,
a terminally ill patient tells the nurse that she does not want any more aggressive
treatment but is pressured by her family and the medical team to ‘continue to
fight.’ The patient’s perspective and wishes are being disregarded but she is
reluctant to cause a ‘fuss’ about it for her family’s sake. However, the nurse does

censure rather than
reactions to patient
needs and
concerns.

Nurse Confidence in Ethical Decision Making: DNP as Transformational Leader

…even when
nurses have had
formal education in
ethics in
undergraduate
curricula,
confidence in
ethical decision-
making wanes over
time.

Nurses need
preparation to
exercise moral
agency and to
develop the skills
to collaborate with
others to articulate
the goals and
expected outcomes
of actions.

not help the patient to convey to the team her wishes because she does not want
to alienate the family or physician with whom she must continue to work.

Alternatively, this nurse may not have been adequately prepared to advocate for patients or has lacked support in
advocating for patient good in the past, and perhaps has even received sanctions. Other examples of expedient
actions include succumbing to pressures to complete tasks in a timely manner, but in the process neglecting the
psychosocial or informational needs of a patient. Milliken (2018) expands on these ideas in her recent article on
ethical awareness. In upcoming discussion, I will expand upon the argument for the central role of nurse leaders
and educators, who will increasingly be prepared at the level of practice doctorates, to support and empower nurse
moral agency using transformative leadership skills.

Literature increasingly describes the problem of moral distress among all healthcare providers. Arguably, point of
care nurses in critical or acute care settings are at highest risk for moral distress, because of their place in the
healthcare hierarchy, and because they are often the ones most intimately aware of patient and family expressed
preferences and worries (Robinson et al., 2014). They also do not always see themselves as having moral agency
(Jurchak et al., 2017).

There is an expanding body of knowledge about nurse preparation for ethical
practice, and mounting evidence that, even when nurses have had formal
education in ethics in undergraduate curricula, confidence in ethical decision-
making wanes over time. This is especially true as the complexity of the
environment increases (Jurchak et al., 2017).

The following all point to the need for cohesive, sustained, multi-modal, ethics education and supports. First, there
is increasing literature about nurse moral distress, where nurses experience a sense of powerlessness and disquiet
when unable to do what they perceive as ‘the right thing.’ Second, over ten years of unpublished data from
evaluations of a mandatory graduate ethics course (n = 447) point to the efficacy of this type of educational
offering in building confidence in their moral agency (Grace, 2018). Third, a recent analysis of reasons that staff
nurses and advanced practice nurses (total n = 67) wanted to join a year-long clinical ethics residency for nurses
(Jurchak et al., 2017) highlighted the desperate need for more ethics education.

Nurses may feel that they are silenced (Malloy et al., 2009) or perceive that their
concerns are not heard and considered (Peter, Lunardi, & McFarlane, 2009; Taran,
2011). Thus, to sustain confidence in one’s moral agency and capacity for ethical
decision-making in contemporary practice settings, more than formal ethics
content knowledge is required. Traditional content, such as history of biomedical
ethics; moral theory and principles; and analytic decision-making techniques are
all valuable tools. Possession of these tools, while foundational for moral agency,
is insufficient for consistent action to address problems (Grace & Milliken, 2016;
Robinson et al., 2014). Nurses need preparation to exercise moral agency
(Liaschenko & Peter, 2016) and to develop the skills to collaborate with others to
articulate the goals and expected outcomes of actions.

Knowledgeable and ethically competent educators and institutional leaders are important. Such leaders understand
the goals and perspectives of the profession as well as those of allied professionals. They anchor their actions as
educators, mentors, resources and supporters in the goals and perspectives of the profession. They employ the set
of tools described above to gather more information; gain clarity about the issues; and to explore nuances of a
situation. Further, they have leadership skills that empower others to develop their moral agency.

Transformational
leaders in nursing
understand
professional goals
and the ethical
warrants of nursing
practice…

Ethically Skilled Educators and Leaders: A Role for Doctors of Nursing Practice

…it is incumbent
on the profession
to ensure that the
ongoing
development of the
DNP role reflects
the ethical
foundations of the
profession…

Transformational leadership skills are those most apt to develop the confidence
and skills of others to achieve mutual goals (Marshall & Broome, 2016; Gaylord &
Grace, 2018). Transformational leaders in nursing understand professional goals
and the ethical warrants of nursing practice and are essential to development of
nurses who are confident in their ethical skills and exercise them on behalf of
good patient and healthcare. That is, transformational leaders are those who can
develop and support the moral agency of nurses at all levels and areas of practice.

Well-designed DNP programs will develop graduates who have gained such transformational leadership skills and
the know how to continue to develop these abilities. Such graduates will be both visionary about what is good
practice and have the ability to support it. From essential domains of knowledge, they will understand the big
picture complexities of institutions; how to influence policy; design supportive work environments; and the
necessities of good patient care. Using a sound understanding of nursing ethics,they will move seamlessly among
these areas to educate and support others to develop moral agency. I believe that good practice is equivalent to
ethical practice, as noted above, because good practice aims to meet the goals of patient and societal health,
wellbeing, and the relief of suffering.

As highlighted in the AACN Essentials of Doctoral Education for Advanced Nursing Practice (2006), doctoral
education in nursing has typically been of two main types, research focused and practice focused. Prior to 2004, a
few universities offered practice doctorates in nursing as distinct from research-intensive doctorates but not under
a uniform title, leading to confusion (AACN, 2004; Reid Ponte & Nichols, 2013). The AACN Position Statement on
the Practice Doctorate in Nursing (2004), among other sources, presented several reasons for rapidly developing
more DNP programs.

There is a growing perception of the need for more highly skilled nurse leaders.
“Increased knowledge and skills [are becoming crucial] for clinical and
administrative leadership across services and sites of healthcare delivery” (AACN,
2004, p.2). This requires advanced preparation in areas not typically covered in-
depth in current nursing master’s programs. There is an ongoing faculty shortage
and DNPs could fill a gap (Brown & Crabtree, 2013). Moreover, strong leadership
is needed in institutional and other clinical settings.

Master’s programs in nursing are already credit-intensive so moving to the DNP as entry level for advanced
practice would better match program requirements, credits, and time with the credential earned. These credentials
would also better match professional clinical doctorates in other disciplines (e.g., pharmacy, dentistry,
physical/occupational therapy). Additionally, the DNP degree provides an avenue of scholarship and leadership that
is not as acutely focused on empirical research as is contemporary PhD study (Grace, Willis, Roy & Jones, 2016),
leaving room for development of sorely needed quality, educational, and safety improvement projects.

“Preparation at the practice doctorate level includes advanced preparation in nursing, based on nursing science,
and is at the highest level of nursing practice” (AACN, 2004, p. 3). The AACN statement also proposes that DNP
preparation will improve the image of nursing. Additionally, PhD prepared nurse scholars are increasingly focused
on developing research trajectories and pursuing necessary funding and resources. Such worthy aims can be all
consuming and lessen available time for teaching (Grace, Willis, Roy & Jones, 2016) adding to the existing faculty
shortage; this represents an area for DNP prepared nurses to make an important contribution.

Since 2004 DNP programs have proliferated and now far outnumber programs offering a research focused PhD in
nursing. There are “303 DNP programs are currently enrolling students at schools of nursing nationwide, and an
additional 124 new DNP programs are in the planning stages (58 post-baccalaureate and 66 post-master’s
programs)” (AACN, 2017, p. 3). Regardless of one’s perspective about whether the move to the DNP as entry-level
advanced practice is a good thing for the profession, evidence suggests that in the coming years there will be a
rapid increase in the number of those prepared at this level. Thus, it is incumbent on the profession to ensure that
the ongoing development of the DNP role reflects the ethical foundations of the profession, and historical as well
as contemporary reasons for its existence (Grace, 2001; 2018).

Transactional
leadership is,
arguably, the most
commonly seen in
healthcare settings
and is managerial
in nature.

Underlying,
implicitly or
explicitly, the
achievement of
each [DNP]
essential is ethical
expertise and
leadership
qualities.

Types of Leadership

Transformational
leadership is
aimed at change.

Relationship of Transformational Learning to Transformational Leadership

There are eight aspects of knowledge and expertise considered ‘essential’ for DNP
graduates to possess in the current (first iteration) AACN (2006) document.
Underlying, implicitly or explicitly, the achievement of each essential is ethical
expertise and leadership qualities. However, how to achieve the essentials is still
at least partially left to each school or college. In the following section, I outline
what is known about leadership and leadership qualities and propose that the
nursing profession should focus on developing ethically savvy, transformative
leaders and that DNP programs are an appropriate medium for this initiative.

Definitions of leadership vary according to author, style, and purpose. A synthesized definition, useful for nursing,
is that leaders are effective in moving a group of people toward a shared goal (Curtis, de Vries, & Sheerin, 2011;
Sullivan & Garland, 2010; Weihrich & Koontz, 2005). In a review of studies on the psychology of leadership, it is
defined as “a process of social influence in which one person is able to enlist the aid and support of others in the
accomplishment of a task or objective” (Chemers, 2001, p. 8580). Regarding the DNP role, I define leadership as
both the capacity to anticipate and envision good practice using nursing goals, knowledge, and perspectives to
shape ultimate aims, and the use of knowledge, skills, and expertise to motivate and empower moral agency in
others. Inherent in this definition is the possession of an ability for critical questioning of personal motivations and
a willingness to critique care environments for the ability to provide good care.

While leadership types and characteristics necessarily overlap, two main types of
leadership are evident in contemporary literature. These are ‘transactional’ and
‘transformative.’ Transactional leadership is, arguably, the most commonly
seen in healthcare settings and is managerial in nature. In transactional
leadership there is a power differential, the leader can direct actions based on a
sort of ‘bartering’ system (Gaylord & Grace, 2018). For example, if you accomplish
the task I have given you in a timely fashion, I will give you a bonus. Within
transactional leadership there are three sub-types (Howell & Avolio, 1993). One
focuses on reward, one focuses on negative feedback, and the third allows things
to proceed without much direction but, when things go wrong, steps in to
remediate. Transactional leadership, then, tends to be task-oriented rather than
innovative, prescient, and creative (Howell & Avolio, 1993; Murphy, 2005).

Transformational leadership is aimed at change (Gaylord & Grace, 2018). The
change may involve all actors including the leader and the environment.
Transformational leaders “energize and motivate their followers to achieve their
goals, share their visions, and embrace empowerment” (Grimm, 2010, p.76).
Transformational leadership is relationship based, and empowers others to actions
of which they had not thought themselves capable (Bass & Avolio, 1994).

Characteristics that are common in transformational leaders include: magnetism; possessing internal locus of
control (i.e., see themselves as accountable for actions); offers inspiration; cognitively curious, questioning
assumptions that are made and willing to be personally challenged by others; and the capacity to focus
simultaneously both on the big picture and the needs of followers. In so doing, these leaders act as mentors and
educators (Chemers, 2010; Cummings et al, 2010; Grimm, 2010). Among the goals of transformative leadership,
related to the nursing profession, is the development of moral agency (i.e., motivation and ability to engage in
ethical actions on behalf of self and others) in nurses (Blacksher, 2002; Liascheno & Peter, 2015).

The concept of transformative learning is also important to develop transformational leaders. Those who aim to
empower others need to know how it is possible to help others transform themselves into moral agents. Theories
of transformational leadership have developed within the education discipline. Mezirow (2009) recognized this
transformational side effect of good education after his wife returned to school to advance her education. Further
research led to the development of the concept of transformational education; education that permits a person to
develop, as such:

Transformational learning is defined as the process by which we transform problematic frames of
reference (mindsets, habits of mind, meaning perspectives) – sets of assumption and expectation –
to make them more inclusive, discriminating, open reflective and emotionally able to change
(Mezirow, 2009, p. 95).

Nursing ethics is at
the base of
everything we do
as nurses.

Conclusion

Author

References

One can deduce from this that the process of transformational learning is complex, takes time, and may involve
some disorientation. Transformational education aims to broaden perspectives and develop increasing comfort with
nuances and ‘grey areas.’ My colleagues and I discovered that our carefully designed, multi-modal, eight hour per
month, 10-month long program, the Clinical Ethics Residency for Nurses (CERN), had a transformational effect
upon our graduates, as evidenced in their discussions and evaluation of the program (Grace, Robinson, Jurchak,
Zollfrank, & Lee, 2014; Robinson et al., 2014). They also evidenced decreased moral distress (Robinson et al.,
2014) and increased their moral agency. Participants included both point of care and advanced practice nurses.
End of program essays (analysis in process) also demonstrated that the majority of participants experienced
personal and professional transformation.

Questions remain about what is needed to ensure that DNP education prepares graduates to be transformational
leaders; how can transformational leadership be maintained; and how can transformational leadership translate to
practice and education settings? A starting place to find answers is to reinstitute the importance of an
understanding of the profession of nursing’s origins, evolution, and reasons for continued existence as a separate
entity from other healthcare professions. We have a unique and central unifying focus on humanizing the
healthcare environment and facilitating “meaning, choice, quality of life, and healing in living and dying” (Willis et
al., 2008, p. E28). Perhaps even more important is that we continue to grow all of our education; curriculum
development; research; and practice initiatives or directives from a nursing ethics matrix.

The rapid proliferation of DNP programs means that, in the future, there could be a substantial cohort of persons
prepared to provide ethics leadership in whatever clinical, institutional, or educational setting they are located. As
transformational leaders they will be sensitive to the ethical nature of all nursing and healthcare practice and able
to communicate this to colleagues, students, and important others as an essential starting point. They will
facilitate the development and moral agency of students, peers, and interdisciplinary colleagues.

Anecdotally, many nursing faculty still view ‘ethics’ as an esoteric topic that can be
taught only by those with philosophy or applied ethics backgrounds. I believe this
is a fallacy. Nursing ethics is at the base of everything we do as nurses. It is
helpful to have knowledge of ethics language and skills in ethical decision-making,
but acquiring this knowledge is not as difficult as sometimes supposed. It is
critically important that DNP curricula, along with the expected knowledge and
skills of graduates, are developed with the professional moral imperative for
individual and social good in mind. We need to situate graduates so that they can
envision, refine, facilitate, and meet nursing goals from a nursing perspective.

Pamela Grace, PhD, RN, FAAN
Email: pamela.grace.2@bc.edu

Pamela Grace is an Associate Professor of Nursing and Ethics at the William F. Connell School of Nursing Boston
College. She is an experienced critical care and advanced practice nurse and educator. She holds a PhD is in
Philosophy (1998) with a concentration in medical ethics. She has written and presented extensively on nursing
and healthcare ethics. Her book, Nursing Ethics and Professional Responsibility in Advanced Practice, (2018) is
now in its 3rd edition and is used internationally as a guide to ethics in advanced practice settings.

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