INTRODUCTION
Since the days of Florence Nightingale, the nursing profession has remained a unique and evolving specialty, but its development has been complicated by the very nature of its own historical relevance, and the ever-changing landscape of current health care delivery systems. As the profession struggles to remain a unified, strong, and valued entity in today’s uncertain and precarious environment, the time is ripe for change.

Robert F. Kennedy said, “Progress is a nice word, but change is its motivator and change has its enemies.”¹ For most individuals, change elicits a negative response; there is comfort and security in familiarity, routine, and repetition. Looking at the nursing profession’s storied past, however, and the challenges Florence Nightingale overcame in her quest to empower nurses and give them a voice, should stimulate and strengthen our commitment to embrace change in this moment of opportunity, and to be leaders in health care delivery. The nursing profession was brought to yet another crossroads by the proposal in 2006 to make the Doctor of Nursing Practice (DNP) degree the profession’s terminal degree by 2015.²

The DNP degree was first defined by the American Association of Colleges of Nursing  (AACN) in 2004. The “Essentials of Doctoral Education for Advanced Practice Nurses,” developed by the AACN in 2006, stated that a DNP graduate should “…demonstrate refined assessment skills, and base practice on the application of biophysical, psychosocial, behavioral, sociopolitical, cultural, economic, and nursing science as appropriate in their area of specialization.” Since then, questions have continued to emerge from nursing organizations about the role of the DNP in their specific environments.³   
   
THE EMERGING IMAGE OF THE DNP CLINICIAN
The focus of the DNP degree is on clinical practice. It is not a specialist degree, but represents a doctorate for advanced nursing practice. The DNP graduate has the opportunity to evaluate current practice and implement strategies directed towards improving care within an evidence-based framework.

As DNP practitioners respond to recommendations for improvements in health care delivery systems, they must be equipped with the knowledge and skill sets necessary to be effective leaders. The advanced practice nurse must be competent and knowledgeable about health care policy, evidence-based practice, information management, advanced technology, quality improvement methods, and interdisciplinary collaboration.

The opportunities available for the DNP graduate are not limited to nurse midwife or nurse practitioner. The advanced practice nurse can serve in a variety of roles in the fields of education, legislation, administration, business, public health, informatics, and integrative health. Public health and integrative health are two rapidly growing areas in which the advanced practice nurse can implement change and develop interventions directed towards the promotion of health, prevention of disease and disability, and creation of healthy environments for both individuals and populations.⁴

As DNP programs continue to emerge throughout the nation, there is continuing confusion about the differences between the long-standing traditional PhD in nursing and the DNP. The PhD is primarily science-based, encompassing all aspects of interdisciplinary research, with an emphasis on developing new knowledge for the science of nursing. In contrast, the DNP is focused on translating nursing research into evidence-based standards of care and practice. The curriculum is rooted in the development of strong leadership and clinical skills. Whereas the PhD requires a lengthy and research-based dissertation, most DNP students complete a capstone project, which closely aligns with their professional interests or area of expertise.

PUBLIC HEALTH NURSING
Florence Nightingale, the first leader who influenced the practice of public health nursing, studied the relationship between environmental conditions and the health of the soldiers during the Crimean War.⁵ Her work was an introduction to the study of epidemiology, which serves as the framework for assessing a population through data collection.

Lillian Wald, one of the most courageous reformers for public health nursing, followed in the footsteps of Nightingale by establishing the first Visiting Nurse Service.⁶ She was an effective and tireless advocate for health, aiding individuals and families through her community work in the immigrant neighborhoods of New York City in the late 1800s. Wald was particularly instrumental in the promotion of women’s health, and was extremely vocal in denouncing the use of children in the workplace. Her successful interventions helped shape the face of public health nursing.

Both Florence Nightingale and Lillian Wald were two prominent and inspirational heroes from the past, yet their actions serve as the basis for the practice of public health nursing of today. Their efforts encompassed the key elements of assessment and policy development, which continue to guide interventions that promote health and prevent disease in both nursing education and practice.

In adopting the leadership skills of Nightingale and Wald, advanced practice nurses have the opportunity to continue the legacy of protecting the health of communities. In doing so they will be guided by the objective topics of Healthy People 2020, and they will be recognized as experts in the field of public health policy.⁷

The DNP–prepared nurse is in a unique position to become a catalyst at the forefront of tackling one of society’s most devastating health care challenges: impaired access for vulnerable populations. As government agencies and medical researchers continue to search for ways to provide quality care for at-risk populations in both rural and urban communities, advanced practice nurses have the necessary skills to drive the transformation of clinical research into nursing practice.

In 2010, the American Hospital Association identified strategies to reduce risks for vulnerable populations and to provide consistent and comprehensive health care equality: improve social determinants of health, utilize global budgeting, provide access to virtual health care, identify at-risk communities, and support community-appropriate health care access and services.⁸  

INTEGRATIVE HEALTH NURSING
In 1980, the American Holistic Nurses Association (AHNA) defined holistic nursing as, “…all nursing practice that has healing the whole person as its goal.” ⁹ The American Nurses Association (ANA) also supports holistic nursing as a specialty, and the American Holistic Nurses’ Credentialing Corporation offers certification to interested registered nurses. At both organizational and individual practitioner levels of health care delivery, the focus has shifted to health promotion and disease prevention to maximize wellness for individuals and families. The priority of care has shifted, along with the traditional role of the nurse, to consistently embrace a holistic approach to care rooted in interdisciplinary collaboration between physicians, nurses, case managers, clients and families, across the continuum of care.

The DNP-prepared nurse will take a prominent role by engaging every client in conversations that foster shared decision-making and shared care planning, and will do so utilizing a team approach with other health care professionals. As the coordination of holistic care promotes quality of care and enhances self-management for the client, the relative roles of physicians and nurses will continually be evaluated. Readmission rates can be reduced by integrating care coordination services, thus providing a seamless plan of service that extends beyond traditional discharge planning.
 
INFLUENCE OF ETHICAL THEORIES ON NURSING PRACTICE
Ethical theories serve as a guide to our actions and influence how we practice nursing. DNP graduates working in the field of either public health nursing or integrative health are in a unique position to promote the health of individuals and populations, but they must do so within the guidelines of the American Nurses Association’s Code of Ethics. All nurses are confronted by ethical dilemmas and challenges daily, but advanced practice nurses with doctoral degrees need the knowledge and confidence to identify and resolve ethical conflicts, based on principles like individual autonomy and personal respect.¹⁰

The principle-based approach combines conceptual thoughts from both teleology^* and deontology.^** Many nurses also consider bioethics as a professional guide of practice, as the concepts of autonomy, nonmaleficence, beneficence, justice, and fidelity are integral to our interactions with patients and families.¹¹ As DNP practitioners fulfill their obligations to clients and their families, their ethical responsibility translates into advocacy with a broader perspective. The ANA and the Public Health Code of Ethics support the protection of the individual and the community from adverse health outcomes.¹² All advanced practice nurses function under their professional code of ethics, thus maintaining the integrity of their profession, and acting in accordance with the principle of social justice.
 
INFLUENCE OF CHANGE THEORIES ON NURSING PRACTICE
Although nurses can rely on a plethora of theories when they seek to stimulate change within their profession and their practice, Kurt Lewin’s three-step theory is widely used and highly applicable. Lewin was a physicist and a social scientist who elucidated the stages of change with the analogy of transforming a block of ice.
 
Stage 1: unfreezing (prepare the organization to realize that change is necessary);
Stage 2: moving (implement the change that has been identified);
Stage 3: refreezing (the change is successful and is stabilized).
 
Time and communication are paramount for any successful change.¹³ The emergence of the advanced practice registered nurse illustrates this staged process. As nurses enter a graduate program and accept the challenge of simultaneously returning to school, working, and perhaps raising a family, they must often also face other barriers. Individually, they may encounter negative attitudes in their administrative or professional colleagues, who may resent or misunderstand their quest for higher education and personal and professional growth.

The anticipated change must first “unfreeze” the mindset of those who work under the premise of false assurance and lateral conflict within the organization. The “moving” phase follows, as others come to view their journey as inspirational, and attach value to their efforts. Finally, the courageous and tenacious graduate will succeed in changing their peers’ thoughts and perceptions, as “refreezing” occurs.

The DNP-prepared nurse will partner with physicians and other health care practitioners to collaborate, organize, and facilitate the care of individuals and families across a wide spectrum of communities.
 
RESPONDING TO THE CALL
As the push towards advanced degrees for nurses continues, educational institutions across the nation are designing and offering customized curricula for practicing nurses. The Pennsylvania College of Health Sciences has responded to the call with a DNP program that offers a blend of online and face-to-face learning with an interdisciplinary approach to graduate education. The post-master’s DNP degree program offers nurses the opportunity to pursue advancement in the field without requiring full-time commitment to a classroom environment. The part-time educational plan is affiliated with Penn Medicine Lancaster General Health, which offers students valuable and unique opportunities based upon individual professional experience.

Registered nurses who are actively employed in the state of Pennsylvania and have successfully completed a master’s degree in nursing from an accredited college or university are eligible to apply. The program is facilitated by experienced faculty and offers academic resources to enhance distance learning for each student. The DNP is an alternative to the more popular terminal degree of the past, the PhD, which focuses on research and teaching as compared to an advanced practice role in the clinical area.

Penn Medicine Lancaster General Health supports the advancement of nurses throughout their hospital system under the Nursing Professional Practice Model. Staff members are encouraged to be active participants in decision-making, which influences positive morale and professional enhancement. The Lancaster General Health Nursing Professional Practice Model is comprised of six sub-councils: Nursing Partners Council, Patient Care Council, Professional Advancement and Engagement Council, Nursing Leadership Council, Nursing Operations, and Communication Ambassadors. Nurse leaders, administrators, educators, and staff nurses are supported and empowered to advance their career through additional coursework, certification, education, and core competencies.
 
CONCLUSION
With the advent of the DNP, and the subsequent curiosity surrounding the purpose, place, and value of such an advanced degree, unanswered questions serve as necessary stimuli to valuable change at the forefront of higher education in the nursing profession. The nation is suffering from a health care system that is plagued by increasing rates of chronic illness, debate over costs and insurance coverage, and the absence of a viable and realistic plan of care for vulnerable populations. The nursing profession has a vision, and a powerful incentive to influence the path of health care, as did Florence Nightingale – the greatest visionary leader of all nurses. As roles are defined and health care professionals unite, the introduction of the DNP may prove to be just what the doctor ordered.

* Teleology: Explanation of an entity or phenomenon on the basis of its function or purpose.
** Deontology: The ethical theory that an action is intrinsically right or wrong based on a set of rules, not on the action’s consequences. Colloquially, this means the ends do not justify the means.


REFERENCES
1. Kennedy RF. www.brainyquote.com/quotes/robertkenn13815html

2. Am Assoc Coll of Nursing. The essentials of doctoral education for advanced nursing practice. Washington, DC; 2006.

3. Slyer J, Levin R. On the Doctor of nursing practice. Research & Theory Nursing Practice: An Intern J. 2012; 26:6-9.

4. Quad Council of Public Health Nurses Organization. Scope and standards of public health nursing practice. 2005; Washington, DC: American Nurses Association.

5. Nightingale F. Notes on nursing: What it is and what it is not. 1946; Philadelphia, PA: Lippincott.

6. https://jwa.org/womenofvalor/wald

7. Zaccagnini M, White K. The doctor of nursing practice essentials, 2nd ed. 2014; Sudbury, MA: Jones & Bartlett.

8. www.healthypeople.org

9. American Holistic Nurses Association. Who we are. http://www.aha.org/Aboutus/tabid/1158/Default.aspx

10. Hamric AB, Reigle J. Advanced practice nursing: An integrative approach, 3rd ed., 2005, Philadelphia, PA: WB Sanders.

11. Beauchamp TL, Childress JF. Principles of biomedical ethics, 7th ed., 2012. NY: Oxford University Press.

12. Green R. The ethics of sin taxes. Public Health Nursing. 2011; 28(1): 68-77.

13. Lewin K. Field theory in social science. 1951; New York: NY: Harper.