558 ■ III: ROLE FUNCTIONS OF DOCTORAL ADVANCED NURSING PRACTICE
a jointly managed nursing primary care practice, much like what happens in the legal
field. We especially predict that these types of doctoral nursing primary care practices
could be competitive for contracts to provide health services, especially to vulnera-
ble populations in medically underserved areas where physicians just do not want to
practice. These environments might include prisons, nurse- managed primary commun-
ity health care centers, inner city and rural health care clinics, and other areas. Banded
together, we predict that a practice of DNP graduates (how about a cadre of transdis-
ciplinary NPs, nurse- midwives, and clinical nurse specialists?) could negotiate real
autonomy and provide expert primary health care in a diversity of health care agencies
and venues. And with certified nurse midwives finally winning 100% reimbursement
under Medicare (since 1988 they have only been reimbursed at 65% of the rate paid to
a physician for the same services) for disabled and senior women needing reproduc-
tive health services and maternity care, maybe even the payment models for advanced
practice nursing care are moving in the right direction (Summers, 2010). However, a
quirk in the Medicare law still prevents APRNs from “signing home health plans of
care and from certifying Medicare patients for the home health benefit” (Conant, 2010,
p. 18). Additionally, physicians are still unnecessarily insistent they be leaders of any
Medical Home practice (Pho, 2013). Nevertheless, with the 2010 Patient Protection and
Affordable Care Act, and real health care reform now in place for 6 years, the future is
bright for DAPN’s, especially if they creatively and innovatively design efficient mod-
els of health care delivery. We are really optimistic about what the DNP practitioner/
clinician graduate can contribute to the new American health care system. Are you?
■ THE DOCTORAL ADVANCED NURSING PRACTICE
“CLINICAL EXECUTIVE”
Given that fundamental change is still needed in the U.S. health care delivery system
to improve quality care, the Institute of Medicine (IOM) has continually published
groundbreaking policy papers,^3 including the 2010 report on nursing, The Future
of Nursing: Leading Change, Advancing Health, in collaboration with the Robert Wood
Johnson Foundation. The doctoral advanced nursing practice– educated clinical executive
(chief nursing officers, vice presidents, and other executive- level nurse leaders) will be
called upon to address emergent and challenging issues for nursing practice, as well as
to create opportunities that will shape and implement innovative changes in our evolv-
ing health care system. But today, the doctoral level clinical nurse executive is in short
supply. Future doctoral- level nurse administrators and executive leaders will also be
charged to improve health and health care outcomes through evidence- based practice in
diverse clinical and health care settings. The clinical executive with doctoral advanced
nursing practice education emphasizes evidence- based and practice- based approaches
for quality and safety improvement in practice settings, applies research methods to
decision making, and translates credible research findings to increase the effectiveness of
both direct and indirect nursing practice. Some of the specific competencies outlined in
the Essentials documents for the DNP clinical executive include: (a) using sophisticated,
conceptual, and analytical skills in evaluating the links between clinical, organizational,
fiscal, and policy issues; (b) establishing processes for interorganizational collaboration
for the achievement of organizational goals; (c) designing patient- centered care delivery
systems or policy- level delivery models; (d) collaborating effectively with legal coun-
sel and financial officers around issues related to legal and regulatory guidelines; and
(e) demonstrating advanced levels of clinical judgment, cultural sensitivity, and systems