The Consensus Model for APRN Regulation, a position statement developed through a collaboration between the APRN Consensus Work Group and the National Council of State Boards of Nursing, itendifies certified nurse-midwives (CNM), certified nurse practitioners (CNP), certified registered nurse anesthetists (CRNA) and clinical nurse specialists (CNS) as the four roles recognized in advanced practice registered nursing (APRN). According to the AACN, APRNs prepared at the doctoral level possess a blend of clinical, organizational, economic, and leadership skills that allow them to critique nursing practice and design programs of care delivery that can have a significant positive impact on healthcare outcomes. The DNP does not alter the actual scope of practice for nurse practitioners and other advanced practice registered nurses. Instead, DNPs work alongside their master’s-prepared colleagues in an expanded role in which they serve as leaders, change agents, and evaluators of care. Transitioning to the DNP or choosing it as the initial path to APRN certification and licensure allows CNPs, CNMs, CRNAs and CNSs to lead, critically evaluate programs of care, and manage change in an increasingly complex and technologically reliant clinical environment. According to The Doctor of Nursing Practice Essentials (3^rd Edition, Zaccagnini and White), nurse practitioners and other APRNs prepared at the DNP level are able to:

• Understand and respect the complementary roles, skills, and abilities of the interprofessional health team
• Successfully collaborate with other professionals to improve the health status of persons or groups and provide an overview of models of interprofessional collaboration in real world settings
• Comprehend organizational and systems improvement, outcome evaluation processes, healthcare policy, and leadership
• Serve as effective collaborative team leaders and participants; participate in the work of the interprofessional team and assume leadership of the team when appropriate
• Share decision making and leadership to best meet the needs of the patient or population
• Possess a thorough understanding of collaboration, communication, team processes, and leadership, and bring forth innovative strategies to improve health and healthcare
• Articulate to the public, insurers, and policy makers the role that nurses play in promoting positive patient and family outcomes
• Promote psychological safety within an organization by providing leadership and recommending resources
• Employ strategies that enhance communication within the interprofessional team setting

Nurse practitioners and other APRNs that hold a DNP are prepared to make a host of unique contributions to advanced clinical practice in ach of their four roles:

Clinical Nurse Specialist

The clinical nurse specialist (CNS) is a systems thinker and clinical practitioner who addresses challenges and changes from within the clinical environment. These challenges and changes may relate to the particular patient population they work with, the disease or area in which they specialize, or the organization for which they work. The DNP-prepared CNS enjoys a unique position on the frontline, in addressing complex and emerging health issues, and in shaping and reforming policy and processes. In 2018, the National Association of Clinical Nurse Specialists (NACNS) board of directors issued the 3rd Edition Statement on Clinical Nurse Specialist Practice and Education, reiterating the set of CNS core competencies expected of DNP graduates originally developed in 2009 through the organization’s Doctoral Competency Task Force. The competencies for CNSs educated at the doctoral level include broad and far-reaching spheres of influence:

• Patient sphere of influence: Encompasses advanced clinical judgment to include pharmacologic interventions and prescribing
• Nursing sphere of influence: Dictates leadership and healthcare team processes that my affect both fiscal and clinical outcomes
• Organizational/system sphere of influence: Includes areas like organizational and systems theory and care that is at once evidence-based, cost-effective, and ethical

The DNP affords the CNS the proficiency necessary to ensure positive outcomes related to the chronic care process. DNP-prepared CNSs are experts in the areas of healthcare policy and economics. This kind of systems-level understanding of healthcare in practice allows CNSs to serve more effectively as clinicians, which helps improve the prospects for positive outcomes. Additionally, epidemiology and advanced evidence-based practice courses give graduates a deeper understanding of the broader implications of managing population health, allowing them to serve as leaders in the quality improvement movement.

Certified Nurse Practitioner

The National Organization of Nurse Practitioner Faculties (NONPF) outlines the skills expected of DNP-prepared nurse pracititoners (NPs). In an increasingly complex clinical environment, healthcare teams rely on DNP-prepared NPs to be experts in:

• Scientific founation of advanced practice nursing leadership
• Quality of clinical practice inquiry
• Technology and information literacy
• Policy
• Healthcare delivery systems
• Ethics
• Independent practice

The DNP is not intended to increase the NP’s level of clinical skills; instead, it is designed to increase the NP’s organizational, economic, and leadership skills, which allows them to bring an organizational-level perspective to clinical practice. This means the DNP-prepared NP has the ability to effect real change in the clinical environment and make the biggest impact on improving patient care and patient outcomes. The additional education nurse practitioners receive at the doctoral level puts them in the unique position of being able to help their patients navigate increasingly complex plans of treatment.

Certified Registered Nurse Anesthetist

According to the American Association of Nurse Anesthetists (AANA), the future of nurse anesthesia education will require a clinical doctorate degree. The DNP recognizes the continuing advancement of the quality and depth of the CRNA education, according to Zaccagnini and White’s The Doctor of Nursing Practice Essentials 3^rd Addition. It also gives additional credibility to the profession and recognizes the tremendous responsibility of the CRNA, who practices lifesaving measures every time anesthesia is administered. After the release of the AACN’s Position Statement on the Practice Doctorate in Nursing, the AANA adopted a task force to examine the push for academic progression and, as far back as 2007, unanimously adopted the position statement in support of the requirements for doctoral education for entry into nurse anesthesia practice by 2025. The DNP provides nurse anesthetists with an education that is comparable to other practice-focused professional degrees like the doctor of pharmacy and the doctor of physical therapy. Therefore, the DNP prepares CRNAs at the highest level, allowing them to transform healthcare delivery by designing, evaluating and continuously improving the framework in which the care is delivered. Further, CRNAs who hold a DNP have the ability to influence the healthcare system by demonstrating effective leadership and by serving as advocates for policy improvements that benefit patients and the practice of nurse anesthetics.

Certified Nurse-Midwife

The practice of nurse-midwifery has a long history of patient advocacy, leadership, service for underserved populations, commitment to providing high-quality healthcare for women and their families, and the development of new models of healthcare delivery. Formally integrating nurse-midwifery clinical pracitce skills into the DNP education allows the CNMs that graduate from these programs to further strengthen the midwifery profession and better serve the women in their care through an organizational-level understanding of health policy and economics. DNP-prepared CNMs have the knowledge and skills necessary to confidently practice and prescribe with full autonomy and serve as leaders and change agents in complex healthcare systems. The DNP advances a CNMs knowledge of:

• Leadership
• Educational and change theories
• Health policy
• Economics
• Midwifery

According to Zaccagnini and White’s The Doctor of Nursing Practice Essentials 3^rd Addition, DNP-prepared CNMs can further advance women’s health by taking on leadership roles in the following areas:

• Development of health public policy as it relates to women and children
• Development of quality measures and data collection tools that promote maternal-child health
• Creation of a healthcare model that safeguards the normalcy of women’s lifecycle events and promotes cultural awareness
• Development of standards for midwifery that promote safe childbearing
• Development of programs that teach women strategies for controlling the cost of the healthcare they receive
• Active engagement in healthcare reform

DNP-prepared CNMs are well-suited to serve as leaders and use information systems, program evaluation, and evidence-based research to enhance the midwifery practice and reinforces the midwifery model of care