DNP-PhD Collaboration in NINR-Funded Physical Activity Trials: A Series of Case Studies

Abstract

Collaboration between Doctor of Nursing Practice (DNP) scholars and Doctor of Philosophy (PhD) scholars is crucial to efficiently advance and disseminate nursing science. Also, DNP-PhD collaboration can help achieve priorities outlined in the recent National Institute of Nursing Research (NINR) Strategic Plan. The purpose of this series of case studies is to describe exemplars of ongoing DNP-PhD collaborations across three NINR-funded trials (1 completed, 2 ongoing) testing physical activity interventions for women at risk for cardiovascular disease. In our three physical activity intervention trials for women, we categorized examples of DNP-PhD collaboration by the four phases of the team-based research model (development, conceptualization, implementation, and translation). Across all three trials, DNP and PhD scholars contributed successfully to all phases of research in an iterative manner. Future work should focus on expanding DNP-PhD collaboration in behavioral trials, which can inform adapted, contemporary models of iterative DNP-PhD collaboration.

Nursing practice must respond to the evolving health care environment, and an efficient, practical process for conducting nursing research is crucial to inform practice in a timely manner. Research findings must be translated quickly to advance evidence-based care in a variety of health settings to improve patient outcomes and eventually to influence local and national health policy.¹ Nurses prepared with the Doctor of Nursing Practice (DNP) and Doctor of Philosophy (PhD) degrees can together lead the advancement of evidence-based practice.

The research-focused PhD in Nursing degree prepares a nurse for a career in the scholarship of discovery, leading programs of research that advance nursing science.² Nurse researchers have established a rigorous science addressing the needs of individuals, families, and communities across the health care spectrum from wellness to chronic disease. Nurses have designed interventions in prevention, self-care management, palliative care, and end-of-life care. There continues to be demand for PhD-prepared nurse scholars to generate evidence to inform innovative and timely advances in evidence-based nursing practice. Yet, the number of students entering PhD in Nursing programs is overall declining.³

In contrast, there is a rapid increase of students entering DNP degree programs, with a nearly 500% increase in the number of graduates from DNP programs across the country in the past decade.⁴ The DNP degree, first recommended by the American Association of Colleges of Nursing (AACN) in 2004, is the highest level of education to prepare nurses for a career as expert clinicians, educators, and/or practice scholars. As more nurses were drawn to the advanced professional role, and with the growing concerns about increased complexity of care for optimal patient outcomes, the AACN expanded the DNP role to include implementation of evidence-based, quality improvement projects.⁵ Thus, according to the AACN DNP competency on Clinical Scholarship, DNPs are now prepared to (a) craft literature reviews, (b) understand research methods, and (c) design, direct, and analyze outcomes to ensure the best, evidence-based care.⁵

We examined existing literature that described examples of DNP-PhD collaboration in research and/or scholarship published in any type of article (e.g., case reports, white papers, descriptive studies). We identified nine papers that described collaboration in research/scholarship alone or combined research/scholarship with practice or education (Online Resource).^6-13 Six of the articles utilized frameworks or models to present their examples. In three articles, the Courtney and Neiheisel model for DNP and PhD collaboration was used to depict the PhD scholar generating knowledge (i.e., research), while the DNP scholar translates knowledge into clinical practice.¹⁴ The Iowa Model of Evidence-Based Practice, which guides nurses on how to use research findings in practice settings, was utilized in one article.¹⁵ The Consolidated framework for implementation research (a framework of constructs specific to implanting research in a variety of settings and disciplines,^16,17 and the San Martín-Rodríguez determinants of collaboration (description of barriers/facilitators to successful interprofessional collaboration) were each utilized in one article. However, all articles applied the frameworks/models in a linear approach, as such the PhD scholars generate knowledge/evidence, followed by DNP scholars who apply the knowledge by translating and integrating the evidence into practice. Previously, a linear delineation of roles in research/scholarship was used to describe DNP-PhD collaboration, though in recent years collaborations have expanded in response to the exponential growth of DNP scholars.^8,18,19

In contrast to a linear relationship, an iterative team-based approach allows for collaboration across the four phases of research including development, conceptualization, implementation, and translation.²⁰ In the development phase, collaborators identify and define the research or clinical problem. The conceptualization phase is to develop formal research questions, hypotheses, theoretical/conceptual frameworks, and study designs to address the identified problem. The focus of the implementation phase is to conduct the research study. Finally, the goal of the translation phase is to apply findings from the implemented research study to advance scientific progress.²⁰ A strength of the phased team-based research model is the potential for collaborations to be iterative, where research findings inform changes in the team composition or approach as well as the direction for the next research projects.

Two studies examined collaboration in the context of descriptive or population research studies, while the other seven studies described collaboration in quality improvement projects or implementing evidence-based guidelines in practice settings. No article looked at DNP-PhD collaboration in the context of a clinical trial. This is extremely important due to recommendations for increased DNP-PhD collaboration in the newly-released National Institute of Nursing Research 2022-2026 Strategic Plan.²¹ These five research lenses presented in the strategic plan could be more fully operationalized by establishing DNP-PhD collaborations in the design, execution, analysis, and dissemination of nursing research. For example, nursing research needs to inform and implement new systems and models of care, which relies on iterative coordination of research and practice.

Purpose

We aimed to present case studies of ongoing DNP-PhD collaborations across three National Institute of Nursing Research (NINR)-funded trials (1 completed, 2 ongoing) testing physical activity interventions for women at risk for cardiovascular disease. We will also categorize PhD and DNP scholar roles in the three case studies according to the four-phase team-based research model (development, conceptualization, implementation, and translation).²⁰ This article will inform the reader of the range of collaboration activities and roles that leverage the distinct, yet overlapping, skills and expertise of DNP and PhD scholars in order to benefit research and rapid dissemination in clinical practice.^6,22

Overview of Three Clinical Trials with DNP-PhD Collaboration

Intradisciplinary DNP-PhD collaboration was integral to three physical activity interventions for women at risk for cardiovascular disease tested in clinical trials (NCT01700894, NCT03558828, and NCT04556305). In addition to PhD-DNP nurse scholars, the three trials included interdisciplinary teams representing diverse disciplines (psychologists, economists, statisticians, neurologists, cardiologists, and computer scientists).

Women’s Lifestyle Physical Activity Program

The Women’s Lifestyle Physical Activity Program (WLPA) was a randomized clinical trial conducted from 2011-2016 (NCT01700894; R01NR004134).^23-26 The purpose of the study was to compare the effects of a lifestyle physical activity intervention comprised of behavioral group meetings alone versus behavioral group meetings supplemented by personal calls or automated calls. Outcomes included the adoption and maintenance of physical activity and weight stability over 48 weeks among African American community-dwelling women ages 45-60 years. The overall objectives for this trial were informed by clinical issues noted in practice and community settings.

The three intervention conditions, guided by social cognitive theory, were randomly assigned across six community health care sites. Participants in all three conditions attended six behavioral group meetings (5 across 24 weeks with one “booster” meeting at week 36). In all three conditions, the overall program goal was to increase physical activity by at least 3,000 steps above the baseline level, which is about 30 minutes of moderate-intensity physical activity. Group meetings included (a) a short video featuring African American women, (b) a discussion led by the group leader using strategies based on social cognitive theory to overcome barriers to physical activity, and (c) review of progression of the individualized step goals based on the woman’s current level of physical activity. One condition received 8 brief (10 minutes) personal phone calls between group meetings that used motivational interviewing to help participants explore and resolve ambivalence about increasing physical activity. A second condition received eight automated phone calls between group meetings that provided motivational messages based on barriers to becoming more physically active. A third condition received only the group meetings. In 288 women, adherence to physical activity and level of aerobic fitness increased at 24 weeks and was maintained at 48 weeks with no differences across conditions.²⁵

Working Women Walking

The Working Women Walking (WWW) program is a recently completed randomized clinical trial that was conducted from 2018-2022 (NCT03558828; R01NR017635).²⁷ This trial tested adaptive interventions designed to improve physical activity (i.e., steps, moderate-to-vigorous physical activity) and improve cardiovascular health among working women who were not regularly physically active. A sequential multiple assignment, randomized trial (SMART) design was used to test combinations of the following four efficacious physical activity treatments: (a) enhanced physical activity monitor (Fitbit wearable activity monitor and mobile app with goal setting and personalized physical activity prescription), (b) text messages, (c) personal calls, and (d) group meetings. The SMART design started with an initial treatment and then transition to an augmented treatment for nonresponders.

A total of 301 women ages 22-69 years who were employed at a large academic medical center were recruited. Participants were randomized to either an enhanced physical activity monitor or enhanced physical activity monitor + text messaging. Nonresponders to the initial intervention at 2 months were randomized to either personal calls or group meetings for the next 6 months. At 8 months, all participants returned to only an enhanced physical activity monitor until their final 12-month assessment. All participants received an enhanced physical activity monitor treatment, which included receiving a Fitbit and a personalized goal. In addition to this treatment, a random sample of half of the participants also received motivational text messages during weeks 1-34.²⁸ At 2 months, nonresponders were randomized to either personal calls or group meetings for the next 6 months. Implementation of the personal phone calls followed the guidelines tested in the WLPA and consisted of total 10 personal calls in weeks 11-34. Implementation of the group meetings also followed the guidelines tested in the WLPA and consisted of five 45-minute group meetings held every four to 6 weeks during weeks 9-34.

MindMoves

MindMoves is an ongoing randomized clinical trial being conducted from 2020-2024 (NCT04556305; R01NR018443).²⁹ The purpose of the trial is to evaluate efficacy of MindMoves, a 24-week multidomain physical activity and cognitive training intervention, on cognition and serum biomarkers in older women with cardiovascular disease (CVD). Women aged 65 years and older with CVD are recruited from two women’s cardiology clinics. A 2 × 2 factorial design is used to examine the main and interaction effects of Mind and Move on cognition and serum biomarkers at 24-, 48-, and 72-week post-baseline.

A total sample of 254 participants were recruited using cardiology provider referral at the time of appointment and mailed letters. Our 24-week multidomain lifestyle intervention (MindMoves) involves a lifestyle physical activity program for older women with CVD (Move), and cognitive training using the BrainHQ program delivered on a tablet (Mind). Participants in the combined MindMoves intervention group complete both programs simultaneously over the 24-week intervention phase. The 24-week Move intervention^30,31 is an adaptation of the WLPA Program.²⁵ Participants receive a Fitbit, a personalized and progressive physical activity prescription, and attend 5 group meetings.³⁰ The 24-week Mind intervention consists of the evidence-based, auditory BrainHQ cognitive training program^32,33 delivered on a tablet.

Examples of Collaboration according to Team-Based Research

We utilized a consensus approach in the coauthor group to categorize the collaboration roles of DNP and PhD scholars in our three case studies. Across our case studies, DNP and PhD scholars contributed to all four team-based research model phases (development, conceptualization, implementation, and translation; Table 1). In the development and conceptualization phases, DNP scholars witnessed a problem in clinical practice and worked with PhD nurse scholars who led the development of the formal research question and study design. For example, DNP clinicians reported low patient physical activity and limited time to devote to providing needed patient education and counseling in health behavior change. The DNP scholars were interested in intervention strategies that could be delivered at the outpatient level. DNP scholars also provided important clinical feedback during intervention adaption and development as clinical partners or as members of expert panels. For example, in MindMoves, DNP scholars were crucial members of the expert panel that informed intervention adaption, including providing feedback on the intervention and its use in women with CVD. Moreover, across all three studies, DNP scholars were instrumental in the development of protocols to assess participants at risk for adverse cardiovascular events and recommended that additional screening and approval from their health care provider was needed prior to participation.

Table 1.

DNP-PhD Collaboration in Three NIH-Funded Physical Activity Trials according to Team-Based Research Phases.

		Team-Based Research Phase
Collaboration Roles	Trial (WLPA, WWW, MM)	Development	Conceptualization	Implementation	Translation
PhD scholars led the development of the research question, hypotheses, study design.	WLPA, WWW, MM	X	X
DNP scholars provided clinical feedback and expertise as clinical partners and/or served on expert advisory panels in the development and adaptation of interventions.	WLPA, WWW, MM	X	X
PhD scholars created study protocol manuals and oversaw training of all research team members.	WLPA, WWW, MM			X
PhD scholars oversaw study fidelity.	WLPA, WWW, MM			X
DNP scholars who worked as nurse practitioners in clinical settings facilitated patient referrals for participation in the trials.	MM			X
DNP scholars conducted health assessments for screening.	WLPA			X
DNP scholars provided training to intervention teams, including interventionists who facilitated intervention groups (i.e., group leader) and motivational phone calls (i.e., motivational caller).	WLPA (group leader, motivational caller), WWW (group leader, motivational caller), MM (group leader)			X
DNP scholars led components of the intervention, served as the group leaders and motivational callers.	WLPA (group leader, motivational caller), WWW (group leader, motivational caller), MM (group leader)			X
DNP scholars served on Safety Monitoring Committees that oversaw trial safety throughout the study timeline.	MM			X
PhD and DNP scholars collaborated and contributed to dissemination activities, including manuscripts, presentations at professional conferences, and clinical presentations.	WLPA, WWW, MM				X
PhD scholars identified the next steps of research identified by study findings.	WLPA, WWW, MM				X
DNP scholars provided clinical feedback in the translation of research findings in clinical and public health settings.	WLPA, WWW, MM				X

Note. WLPA, Women’s Lifestyle Physical Activity Program; WWW, Working Women Walking; MM, MindMoves.

In the implementation phase, PhD scholars oversaw the study protocol development, trained data collectors, and monitored study and intervention fidelity. During implementation, DNP scholars referred patients from clinical practices for study participation, screened potential participants for eligibility, trained interventionists who facilitated groups or completed motivational calls, delivered intervention components (e.g., led group meetings), and served on data and safety monitoring committees. For example, in the WLPA trial, a DNP scholar participated in administering the health assessment screenings, which included the critical measures to determine eligibility for the study: health history, physical examination, blood pressure, a resting 12-lead electrocardiogram, and point-of-care fasting finger stick for lipoproteins and glucose and when indicated, hemoglobin A1c. Also, a DNP scholar developed a standardized group interventionist training module based on the three components of the centering model espoused by the Centering Healthcare Institute: health care assessment, education, and support. The DNP scholar expert used the manual to train both DNP and PhD interventionists in the delivery of groups in all three trials (WLPA, WWW, and MindMoves). Further, standardized motivational interviewing training for PhD and DNP interventionists in the WLPA trial as well as the WWW trial was conducted by a DNP scholar trained with extensive training and clinical experience in motivational interviewing. In the WWW study, a DNP-prepared interventionist delivered part of the augmented treatment at the point of second randomization for nonresponders. In MindMoves, a DNP scholar was also a valuable member of the Safety Monitoring Committee.

In the translation phase, DNP and PhD scholars worked together to interpret findings and collectively informed dissemination efforts such as manuscripts and presentations. PhD scholars identified the next steps of the research based on the study findings, while DNP scholars provided clinical insight on the translation of the research to clinical and public health care settings. To facilitate collaborative dissemination, the DNP and PhD scholars collaborating in the studies were invited to meet at ongoing weekly meetings to provide input on findings for posters, presentations, papers, and future grant development. Overall, DNP-PhD collaboration activities took place in an iterative manner across all four phases.

Taken together, DNP and PhD scholars collaborated iteratively throughout the continuum of each of the three clinical trials. As noted, some collaborations extended beyond the single study and took place across multiple research studies. Building on the success of the collaboration throughout the three clinical trials, it is time to continue the DNP-PhD collaboration. For WLPA, the next step includes dissemination and implementation of the trial findings into practice, led by the DNP scholar. For the WWW and MindMoves trials, study results may inform additional refinement following the same team-based research model phases.

Discussion

Nurse scholars with either practice-focused DNP or research-focused PhD degrees are well suited to collaboratively engage in research and scholarship to improve health outcomes. However, existing examples of DNP-PhD collaboration in research were limited. Authors described strict delineation of roles that occur sequentially (e.g., the PhD scholar generates evidence while the DNP scholar translates the evidence into practice) rather than iteratively. As such, examples of collaboration were sequential versus iterative across all phases of research. Moreover, authors provided examples of DNP-PhD collaboration in the context of quality improvement or descriptive research studies with no examples of NIH-funded clinical trials testing behavioral interventions for clinical or public health populations.

We provided three case studies of DNP-PhD collaboration in physical activity trials funded by NIH. We described DNP and PhD scholar roles across the development, conceptualization, implementation, and translation phases of research and scholarship using the four-phase model of team-based research.²⁰ This model was originally intended for application for research collaboration across differing disciplines (e.g., nursing and psychology) versus collaboration within disciplines (i.e., intradisciplinary collaboration between specialties or degree preparations). Yet, a strength of the team-based research model is the four-phase model that reflects the potential for collaboration across all phases of research and scholarship. This contrasts with the current sequential approach in models of DNP-PhD collaboration, such as the Courtney and Neiheisel model for DNP and PhD collaboration, the only model originally developed for application in DNP-PhD collaboration. This model is centered on the evidence-based practice enrichment cycle and delineates DNP scholars as leading knowledge application (e.g., translation, implementation), while PhD scholars lead knowledge generation (i.e., independent research of phenomena). Although this model was especially developed for DNP-PhD collaboration, DNP-PhD collaboration in research has evolved, and the linear approach in the Courtney and Neiheisel model may no longer encompass the full potential of DNP-PhD collaboration for a team-based approach to nursing research.

An adapted model of DNP-PhD collaboration for research and scholarship that reflects flexible, iterative collaboration may be preferred for efficient identification of clinical problems and dissemination into practice, while also recognizing the full scope of DNP and PhD scholar expertise. Based on the existing literature and our examples of DNP-PhD collaboration across three trials, we propose that an updated model of DNP-PhD collaboration include the following aspects: (a) DNP and PhD scholars are involved in research and scholarship of all methodologies including trial designs, (b) DNP-PhD collaboration occurs across all research phases, ranging from development to translation or dissemination, and (c) DNP-PhD collaboration in research and scholarship is concurrent, iterative, or both. The inclusion of such DNP-PhD research teams would greatly benefit the generation and application of nursing knowledge.

This article has limitations. Although DNP and PhD scholars both contributed to all stages of research, this series of case studies represents collaboration in physical activity clinical trials originally initiated by PhD scholars. We did not present case studies of collaboration in research/scholarship projects that were initiated by DNP scholars. However, dissemination and implementation of the trial findings led by DNP scholars is the next step of this important work. Second, to examine DNP-PhD collaboration in our three case studies, we utilized the team-based research model, originally designed for application in transdisciplinary research versus intradisciplinary research (i.e., between DNP and PhD nursing scholars). Nonetheless, this is the only article to our knowledge that explicitly described DNP-PhD collaboration in the context of NIH-funded behavioral trials across all phases.

Conclusion

Approaches to DNP-PhD collaboration that utilize team-based, iterative processes can offer several benefits. Such collaboration can help identify timely and urgent issues in health care and public health, inform realistic and targeted interventions suitable for practice settings, and aid in the efficient and applicable translation of research into practice. Researchers should leverage DNP-PhD collaboration across all phases of research to obtain such benefits. Future work should focus on the adaptation or development of a model of a DNP-PhD collaboration to inform future research studies and scholarship projects. Another opportunity for additional attention is the development of practical guides offering concrete strategies for identifying, coordinating, and maintaining DNP-PhD collaborations in research and scholarship.

Supplementary Material

Supplemental material for this article is available online.