When registered nurse Joan Ching went back to school for a doctorate in her early 50s, she was eager to return to the classroom.

“I really believe in lifelong learning, and nurses are kind of an odd bunch of people in that our education is never done,” she says. “I went back to school … once I realized that the DNP (Doctor of Nursing Practice) was going to be a return on investment for me.”

A changing landscape

Advance practice nursing — that which requires postgraduate education — is an in-demand profession. The Bureau of Labor Statistics projects that overall employment of nurse anesthetists, nurse midwives and nurse practitioners will grow 31% from 2016 to 2026, much faster than the average for all occupations. In 2004, the American Association of Colleges of Nursing issued a statement calling for increased educational preparation for advanced practice nurses. While a Master of Science in Nursing remains the minimum standard, new technologies, workplace policies and national concerns about patient care and safety are changing the landscape.

“My guess is that by 2025 you will see very few programs in the country offering the MSN any longer,” says Dr. Kristen Swanson, dean of Seattle University’s College of Nursing.

The educational replacement endorsed by the AACN is the DNP — a degree program that equips students with skills beyond the bedside to affect change in both clinical and leadership roles. More specifically, DNP graduates will have the credentials to participate in and question processes within their hospitals and other health care organizations.

Swanson says the shift is long overdue. “In context, physical therapists, pharmacists, occupational therapists and many other health care professions went to the doctorate (programs) much faster. I think it’s because those professions are not as large and there are not as many folks trying to hold on to the way it was,” she says.


“The way it was” exposes the underpinnings of an outdated health care infrastructure — one that relies on nurses without giving them an equitable voice when it comes to policy. There are 3.9 million nurses in the United States, according to a World Health Statistics report, representing the largest section of health care workers. While nurses are undoubtedly crucial, a 2015 survey in the Scottish journal Annals of Behavioral Medicine found that feeling undervalued was more stressful for them than caring for patients.

Numerous research studies have cited the correlation between nurse preparedness and improved patient outcomes, says Ching, who now serves as the director of health care consulting at Moss Adams in Seattle. She says the institutionalized lack of representation can be traced, in part, to billing.

Dr. Joan Ching is the director of health care consulting at Moss Adams in Seattle. (Courtesy of Joan Ching)
Dr. Joan Ching is the director of health care consulting at Moss Adams in Seattle. (Courtesy of Joan Ching)

“The political aspect of this is that nursing care is part of the room rate: The labor factor is calculated into the room rate of how much a medical/surgical bed costs,” she says. “Nurses can’t bill like physicians or even pharmacists, and so without that voice of sophisticated nurse leadership communicating the value of nursing — that can’t be captured in anything but room rate — our very important profession is only going to be at its best in its current state.”

Promoting positive change

Seattle University is among the regional institutions whose advanced nursing programs have shifted to align with the AACN’s recommendations, along with the University of Washington, Seattle Pacific University and Gonzaga’s online DNP program. According to Dr. Bonnie H. Bowie, assistant dean of graduate education at Seattle University, the DNP coursework provides the theoretical and practical knowledge doctoral nurses need to pursue change and advocate for their patients.   

“We want our students to have the skills to be able to move change through complex systems,” she says. “How does one go about that? They take a class in health care finance and economics, for example, to give them some financial tools about cost-effectiveness.

“They can ask themselves, ‘If I want to propose a new service within my clinic that I see is needed for my patients, how can I put together a business plan that shows this will be cost-effective in the long run?’ The education they receive gives them the skills and confidence to recognize where change is needed and follow through.”


As new standards become the norm, the growing number of doctoral nurses in American health care will place a greater emphasis on an evidence-based quality of patient care, says Swanson. For Ching, it’s a change that can’t come soon enough.

“I’ve been in the position of hiring nurses, and if you look at the amount of time that (DNP) students spend in the clinical setting, as well as the kinds of courses they take — everything from community health assessment to informatics to health care financing — the depths of their exposure is the skill set needed in 2019,” says Ching. “That’s the mindset I’m looking for.”