In the Vanguard

What do you call a degree for nurses whose advanced, comprehensive clinical training places them at the apex of their profession? To anyone familiar with the field today, the answer is obvious: a doctor of nursing practice, or DNP. However, that riddle was unsolvable until 2004, when the Columbia University School of Nursing became one of the first institutions to confer such a degree.

The school’s DNP program, which celebrates its 20th anniversary this year, has since been joined by some 400 others across the United States.

Their progenitor at Columbia has grown exponentially, now graduating over 100 students each spring, and is widely recognized as one of the leading DNP programs in the country. Its alumni have gone on to serve in some of the most demanding positions the field has to offer: as senior nurse practitioners in complex medical settings, graduate-level nursing educators at major academic institutions, and leaders of health care organizations ranging from urban maternity centers to federal substance-use programs.

The program has also served as a model for many that came after it—particularly those dedicated to preparing top-notch clinicians, rather than nurses interested in indirect-care roles such as policy development, informatics, or administration.

“We continue to be laser-focused on improving patient outcomes by producing an astute, well-educated nurse practitioner who understands the context in which care is delivered,” says Judy Honig, DNP ’05, EdD ’95, who will retire at the end of this academic year as vice dean of academics and dean of students; she not only helped design the program but was among its first graduates. “Our students come away with a deep knowledge of the health care landscape,” she adds, “and unparalleled expertise in the care modalities specific to their specialty.”

That clinically oriented approach to DNP education may not sound controversial. But it was revolutionary 20 years ago—and it remains rare today.

Columbia Nursing’s DNP program was conceived by Dean Emerita Mary Mundinger, DrPH, who took the helm in 1986—one of the most difficult periods in the school’s history. Like many nursing schools at the time, Columbia’s was suffering from budget cutbacks and enrollment declines; university officials were considering shutting it down. Instead, they asked Mundinger (who was assistant dean for health policy at the medical school, after a stint directing the nursing school’s master’s program) to return to the school and try revitalizing it. 

After being appointed dean, Mundinger recalls, “I took some pretty radical steps.” The first was to downsize the faculty by nearly two dozen members who were not willing to take on the challenges she felt were necessary. “We were left,” she says, “with a very small but loyal and excited cohort of people who wanted to see the school transformed.” With that group, she instituted committees to re-envision Columbia Nursing’s approach to issues like education, clinical practice, research, and health policy. A series of sweeping reforms followed.

In 1988, Mundinger unveiled what came to be known as the Columbia Model of nursing education. Its central feature was the nation’s first universal faculty practice plan in nursing. Instructors with doctorates, classified as “research scholars,” were required to conduct research in nursing or a related field. Non-doctorally prepared faculty, or “clinical scholars,” were required to participate in an outside clinical practice that offered opportunities to develop or test nursing theory or methodology. This new mandate attracted growing numbers of highly credentialed faculty, as well as talented and ambitious students. 

In 1994 the school leveraged its emerging research prowess by launching a part-time doctor of nursing science (DNSc) program, which eventually morphed into a full-time PhD program. The following year saw the birth of Columbia Nursing’s faculty practice in Washington Heights—the Center for Advanced Practice (CAP), the first independent primary care practice staffed by nurse practitioners; today, it’s known as the ColumbiaDoctors Primary Care Nurse Practitioner Group.

Thanks to Mundinger’s negotiating acumen, two things distinguished Columbia’s NP practice from most that followed in its footsteps: Its nurses had full authority to admit and treat patients at the university hospital, and they were compensated at the same rate as primary care physicians (PCPs). Those features reflected her belief that well-trained NPs could do anything PCPs could do. “If a patient in your outpatient practice was hospitalized,” she explains, “the nurse who was their primary care provider would be able to follow them in the hospital. They’re not going to take care of a heart attack, any more than a primary physician would, but they’d have the same oversight over other conditions, like making sure the patient’s diabetes remained under control.” They could then discharge the patient back to their practice, as primary physicians did.

To ensure that Columbia NPs had the skills they needed to handle such responsibilities, Mundinger arranged a partnership with Columbia University Irving Medical Center’s Department of Internal Medicine, whose faculty provided one-on-one mentoring. And to test her theory that NPs could match physicians in providing primary care, she led a clinical trial comparing health outcomes over the course of a year among several hundred patients treated at CAP and a similar number of patients treated by physicians at NewYork-Presbyterian Hospital. Published in the Journal of the American Medical Association in 2000, the study found no significant differences.

By then, other nursing schools were showing interest in Mundinger’s approach to educating NPs who could perform at the top of their licensure and across the continuum of care. “I thought, maybe we should formalize it, so that they could do the same thing,” she says. She also recognized that CAP’s mentoring model would be difficult to scale up if nurses were to expand their role in the health care system at large. So she convened a committee to design a doctoral program in clinical practice—distinct from the research focus of a DNSc or PhD.

Meanwhile, support for the concept of a DNP was growing across the profession. In 2002, the American Association of Colleges of Nursing (AACN) appointed a task force to study practice-based doctoral programs in other fields and make recommendations for their implementation in nursing.

In June 2004, the Columbia University trustees approved the new degree, and the first contingent of students enrolled in the program that fall. Although one other nursing school offered a DNP, stressing administrative skills, Columbia’s was the first to focus on clinical competence. In October, the AACN task force released its report, calling for more such programs across the U.S.

The AACN document, however, had what Honig (who served on the task force but dissented from its conclusions) calls a “fatal flaw”: Its concept of DNP education embraced not only the direct care of

patients, but also areas such as administration and policymaking. “They defined the degree to be so broad that it encompassed anything a nurse does,” Mundinger says. “It no longer signified advanced clinical practice.”

Of the hundreds of subsequent DNP programs, only 15% were clinically focused, according to a 2019 paper coauthored by Mundinger in the journal Policy, Politics, and Nursing Practice. “That’s been a disappointment,” says Honig.

But Columbia’s DNP program has stayed true to Mundinger’s vision. The first enrollees included about a dozen faculty members and administrators—veteran advanced practice nurses who’d long dreamed of earning a clinical doctorate. Several, like Honig, went on to teach in the program as its enrollment expanded.

In fact, the current director of the DNP program is an alumna who entered the program just a couple of years after its establishment. Susan Doyle-Lindrud, DNP ’08, now the assistant dean for academic affairs at Columbia Nursing, was an NP at a comprehensive cancer center when she enrolled in the nascent program. 

She’d been thinking about going back for a doctoral degree, she explains, but felt that a practice-focused doctorate would be the best fit for her—and yet such a program didn’t exist at the time. “When I first heard about the Columbia program,” she says, “I knew it was what I’d been waiting for.” 

“Completing the DNP degree changed the course of my career dramatically,” Doyle-Lindrud continues. “I had every intention of taking the skills I learned and staying in clinical practice full-time, but soon after I graduated the school asked me to come back and teach oncology courses. Soon after that, I was appointed coordinator of the oncology subspecialty, and I’ve been on the faculty ever since.”

Another student whose horizons the program expanded was Edwidge Thomas, DNP ’05, who’d immigrated from Haiti to New Jersey with her family as a child. After earning her BSN from Rutgers and working at NewYork-Presbyterian, she graduated from Columbia Nursing’s master’s program in 1993 and then took a job at King’s County Medical Center in Brooklyn. There, she learned to care for patients who were medically underserved and socially marginalized—like people she’d grown up among. 

Then her mother died of a heart attack, after experiencing warning signs her cardiologist had dismissed. “I realized,” says Thomas, “that even as a medical professional I’d been unable to protect my mother from the disparities of care afflicting women of color. So I decided to invest my anger and energy in trying to change the tide.” She began doing so as a clinical assistant professor at Columbia and a founding member of CAP and next as the clinic’s director, enhancing care for its largely impoverished and nonwhite clientele. When the DNP program was launched, Thomas signed up immediately, knowing a doctorate would help her further her mission.

After graduating, Thomas became director of clinical practice affairs at NYU’s College of Nursing, where she led an NP-managed primary care practice modeled on CAP and a mobile health van program for immigrant teens. Her next job was at Mount Sinai, as clinical lead of the hospital’s Delivery System Reform Incentive Payment (DISRIP) program—a federal effort that incentivizes states to improve health care quality and cost efficiency. In her current position, as vice president of clinical solutions for Northwell Holdings, she develops new offerings for the vast Northwell Health system. To feed her soul, she volunteers as an NP at a clinic for low-income patients and is an adjunct professor at Columbia Nursing. And she recently received a $100,000 grant from Johnson & Johnson to establish a scholarship in her name, for nurses from underrepresented and marginalized communities in pursuit of graduate education.

“None of these amazing roles I’ve had would have been possible without this degree,” Thomas says. “And I’ll go a step further: They wouldn’t have been possible if my degree hadn’t been from this school. The training and experience I received, and Columbia’s reputation for excellence, has opened doors that might not have been so open if my DNP had come from somewhere else.”

The program was also transformative for Lora Peppard, PhD, DNP ’08. She majored in international business in college, but a stay in a German hospital with a herniated disc left her with a deep appreciation for nurses. After returning to the States, she earned a master’s in advanced practice psychiatric-mental health nursing from Boston College and spent a few years as a psychiatric nurse practitioner. Then she read about Mary Mundinger’s program at Columbia. “I was all in with her vision for the DNP,” Peppard says.

“I was struggling with trying to get clients medication or services in a timely manner due to insurance or access issues,” she recalls. “I experienced challenges throughout the entire system, and I was hungry to ... be part of the solution.”

At Columbia, Peppard found that “systems thinking was promoted throughout the curriculum, including a course exploring how clients travel through the micro, meso, and macro systems of health care. We added tools to our toolbox by developing business plans, conducting systematic reviews of the literature, and appraising and translating science for multiple consumers.... For someone who was eager to learn, it was heaven.”

After completing her degree, Peppard initially went back to clinical practice. Soon, however, George Mason University recruited her to help start a DNP program and a psychiatric nurse practitioner concentration, then to establish behavioral health services in a network of clinics for low-income patients. She also began teaching as an adjunct professor at Columbia Nursing and providing services to community mental health clinics. In 2015, George Mason asked her to launch a regional Screening, Brief Intervention, and Referral to Treatment (SBIRT) training program, part of a federal early intervention approach for substance misuse; soon she was implementing the SBIRT strategy at health care systems across Virginia. “That was when I entered the substance use prevention space,” she says, “and I’ve never looked back.”

Today, Peppard is executive director of the University of Baltimore’s Center for Advancing Prevention Excellence; director of a national training and technical assistance substance use prevention division funded by the federal High Intensity Drug Trafficking Area (HIDTA) program; deputy director for treatment and prevention of the Washington/Baltimore HIDTA; and president of the American Psychiatric Nurses Association. “Columbia Nursing’s DNP program prepared me for this whole adventure,” Peppard says. “It gave me the knowledge, the skill set, and the courage to go where I’m needed.”

For students currently in the school’s DNP program, the adventures are just beginning. Ian West, MS ’22, is one of them. He grew up outside of St. Paul, Minnesota, and earned an undergraduate degree in psychology and neuroscience, plus a master’s in kinesiology, from the University of Minnesota. Then he bounced around a bit. Moved by the suffering of a young concussion survivor he met while coaching high school hockey, he did a research fellowship on pain management at Tufts University School of Medicine; next, he worked as a researcher at the Mayo Clinic, focusing on substance use and rural mental health. But he was struck by the gap between the lived experience of his research subjects and the constraints of the protocols used to study them.

Meanwhile, he kept remembering a nurse who’d been one of his mentors at Tufts. “I’d talk with her about the role of social determinants in chronic pain, and she’d tell me, ‘Hey, this is what nursing is all about. We look at the intersection of all these different factors in life, not just the biology.’” Eventually, he became convinced that pursuing a DNP could lead him to the understanding he’d been seeking.

West chose Columbia for both its academic rigor and its location: As a lifelong Midwesterner, he figured that moving to New York City would be an education in itself. He started the MDE program in 2021, completed it the following year, and expects to receive his doctorate as a psychiatric nurse practitioner this May.

One of West’s biggest revelations in the master’s program was that “psych is everywhere,” as he puts it. “On every floor, med surg to labor and delivery, you’d see mental health issues of every kind.” Another was that he loved working at the New York Psychiatric Institute, the site of his final clinical rotation.

Once he entered the DNP program, West was surprised by a rotation at the Bloom Foundation for Maternal Wellness, caring for women with postpartum depression and anxiety. He took the assignment on the advice of Laura Kelly, PhD, then director of the Psychiatric Mental Health Nurse Practitioner Program. “She told me, ‘This will force you outside of your comfort zone,’” West says. “‘That’s how you grow.’” For the first few weeks, he felt at sea—separated from the patients by gulfs of gender, culture, and experience. But he found ways to connect, and he emerged more confident of his ability to navigate such challenges.

West has surprised himself in other ways as well, discovering unexpected talents for teaching (he recently won a TA of the Year award) and leadership (he’s recruited fellow students for jobs at the Psych Institute, where he continues to work). Although he’s still not sure what he’ll do after he completes his DNP (work at a hospital? start a private practice? freelance as a consultant?) he’s not worried. “My calling is to make health care better,” he says. “The good news is, I have lots of options.”

Another current student, Kelly Rojas, MS ’23, is a couple of years behind West in her studies but surer of her future path: She aims to become a family nurse practitioner, providing primary care to low-income patients in a Federally Qualified Health Center. 

Rojas has dreamed of being a nurse since she was a little girl. The daughter of Mexican immigrants, she grew up in a low-income household in Yonkers, where she saw many in her community seeking care only in emergencies. “That’s what kickstarted my career choice,” Rojas says. “Primary care is so crucial. Yet so many people in underrepresented communities don’t have health insurance or can’t take time off from work to see a provider.”

The calling grew more urgent for Rojas in her early 20s, when one of her uncles was diagnosed with a glioblastoma. “He didn’t seek treatment until he experienced an excruciating headache and had to go to the ED,” she says. “He wound up needing emergency brain surgery that same day. Looking back, he was like, ‘I did have these headaches before. I should have gotten them checked out, but I couldn’t afford it.’”

Rojas, who was working as a medical receptionist, became his primary caregiver and liaison with the health care system. After chemotherapy and radiation proved ineffective, she found a clinical trial that gave him access to an experimental medication. That treatment bought her uncle a few more months, but he died at age 38, shortly before Rojas entered Columbia’s MDE program.

Throughout the ordeal, however, she found a pillar of support in the nurse practitioners who cared for her dying uncle. “They were the ones on top of his case, who we’d see consistently at follow-ups,” Rojas recalls. “That personal relationship with patients and family members is pivotal. As a nurse, you understand the importance of being with them in the moment."

And that, Rojas says, is what she hopes to give her own patients and their loved ones. She’s pursuing a DNP, she says, for one simple reason: “To be as educated as possible to serve the community I want to serve. I want to give them the best, most up-to-date care that I can.”

As Judy Honig stresses, that’s been the point of Columbia’s DNP program since the beginning. “The content of our courses has evolved with the times,” she says, “but our mission remains the same.”