Abstract
PhD-prepared nurse practitioners (NPs) bring a unique combination of attributes to work within university settings. However, models for integrating clinical practice within academia are lacking for nursing faculty. As four PhD-prepared NPs, we completed a pilot collaborative self-study to explore how PhD-NPs working in academia experience the integration of clinical practice with academic work, and how clinical practice fits within workload and academic promotion models. Following initial data collection by email, we conducted a virtual focus group and analyzed the data using Braun and Clarke’s Reflexive Thematic Analysis. Identified themes included the value of clinical work; lack of understanding of the PhD-NP role; synergy between teaching, research, and clinical practice; challenges including time constraints and competing responsibilities; and the lack of formal models for PhD-NP role organization and compensation. PhD-prepared NPs felt clinical work added value to their teaching and research, although academic-clinical role organizational models were lacking. This pilot data must be contextualized within current North American policies and practice settings. Findings can be used to inform further study on the development of models for clinical practice in academia.
Keywords
Introduction
PhD-prepared nurse practitioners (NPs) bring a unique combination of attributes to work within university settings, where they teach, conduct research, and provide community service. However, models for integrating and valuing clinical practice within academia are lacking. According to a 2024 U.S. survey, only 1.3% of 10,275 NP respondents held a PhD (American Association of Nurse Practitioners, 2024), while in Canada, there are insufficient PhD-prepared nurses to fill faculty vacancies, reflecting the current global shortage of nursing faculty (Boamah et al., 2021; Vandyk et al., 2017). With a need to expand the capacity of the nursing workforce (Buchan & Catton, 2023), the shortage of nursing faculty has the potential to exacerbate the shortage of nurses more generally. In addition to undergraduate nursing programs, the number of U.S. and Canadian graduate-level NP educational programs and respective enrollments have increased rapidly (Ainslie et al., 2024; Government of Ontario, 2023). In the United States, the Doctor of Nursing Practice (DNP) degree is now the recommended point of entry to the NP profession, with increasing numbers of NPs completing a DNP program (Ainslie et al., 2024). This growth has led to a corresponding need for NP tenure track and clinical track faculty appointments.
In North America, traditional academic tenure track appointments require nursing faculty to achieve success in the three domains of teaching, research, and service to obtain reappointment, promotion, and tenure. Clinical faculty generally have heavier teaching workloads, are expected to practice clinically, and are usually not considered for tenure. The requirements for scholarship for clinical faculty have evolved differently, in part due to the requirements for and extra demands of clinical practice, as well as the workload associated with supervising students in clinical settings. Tenure track faculty are likely to spend a greater portion of workload time on service and research, while non-tenure track or clinical faculty spend more time on clinical teaching responsibilities (Bittner & Bechtel, 2017). However, even for clinical faculty, there is no universal model to guide how their clinical practice should be integrated, valued, or evaluated (Gourley et al., 2024).
PhD and DNP: Research and Practice Doctorates and the Nurse Practitioner Role
The PhD degree has traditionally been the terminal academic degree for nurses. In the United States, many (but not all) clinical faculty now hold the DNP degree, while in Canada, although the DNP is an option, the PhD remains the most common terminal academic qualification for nurses (Registered Nurses Association of Ontario, 2023). The PhD degree is focused on research and the generation of new knowledge, while the DNP degree is focused on translational science and evidence-based practice (Melnyk, 2013). The American Association of Colleges of Nursing (AACN) endorsed the DNP degree as the graduate degree for entry to advanced nursing practice in 2004 (American Association of Colleges of Nursing, 2004). DNP and PhD-prepared faculty have different skills; both may be found within academic settings, with those holding PhDs more common among the tenure-track and tenured complement.
The NP, an advanced practice nurse, contributes nursing expertise that differs from that of the registered nurse (RN). Of 10,275 NPs surveyed for the AANP 2024 Nurse Practitioner Practice Report, 1.2% reported that they held a PhD, while 17.6% held the DNP degree (American Association of Nurse Practitioners, 2024). Although the number of PhD-prepared nursing faculty in Canada has been reported to be near 2,500 (Canadian Nurses Association & Canadian Association of Schools of Nursing, 2012), it is difficult to know how many PhD-prepared faculty are also NPs; they are almost certainly underrepresented in the broader post-secondary educational sector.
NP Practice Requirements
To practice as an NP, individuals must maintain both national certification (achieved by passing a certification exam), and a license or registration issued by their state, province, or territory. In the United States, national certification as an NP is generally through one of two bodies – either the American Association of Nurse Practitioners Certification Board (AANPCB) or through the American Nurses Credentialing Center (ANCC). In Canada, current certification exams include the AANC, AANPBC, and the Canadian Nurse Practitioner Exam; as of 2026 a single-entry national exam will be rolled out (Canadian Council of Registered Nurse Regulators, 2024). Ongoing nursing certification maintenance varies by exam board. For example, the AANPCB requires that NPs either complete 1,000 practice hours plus continuing education hours within the 5-year renewal period, or that they re-take the certification exam (American Academy of Nurse Practitioners Certification Board, 2024). The ANCC requires continuing education and allows (but does not require) NPs to count practice hours for re-certification as one of several options including research, academic study, precepting, and professional service (American Nurses Credentialing Center, 2022). License or registration requirements vary by state and province, and many require clinical practice hours. University accrediting bodies may also require faculty to maintain a clinical practice to teach in programs that prepare nursing or NP students for entry to practice. For example, the U.S. Commission of Collegiate Nursing Education requires that faculty who teach clinical classes maintain their clinical expertise, although this is specified as “clinical practice or other means” (p. 13) and also requires institutions to provide support to allow clinical practice maintenance by those faculty who need it (Commission on Collegiate Nursing Education, 2024).
The Current Study
The current collaborative self-study grew from conversations we, as four PhD-prepared NPs working within academia, had about our challenges maintaining or obtaining a clinical position alongside a tenured or tenure track academic appointment. We realized that our strong shared commitment to maintaining our clinical practice while working as academic faculty came with shared challenges around balancing clinical and academic responsibilities. Given the richness of our initial conversations, and their resonance with our professional trajectories, we decided to formalize our discussions through use of email interview questions and a focus group, to generate pilot data. Our aims were to: explore the implications of integrating academic and clinical roles for PhD prepared NPs; consider how clinical practice fits within workload and academic promotion models; and gain insight into the experience of PhD-prepared NPs combining academic and clinical roles.
Methodological Approach
Collaborative Self-Study
Self-study has been proposed as a method by which a researcher and professional learner can explore their own practice, reflect on professional practice, engage in continuous learning, and improve both practice and the practice environment (Woods, 2021). The definition of self-study as a research approach should be distinguished from the use of the term self-study as an approach to mastering material by individuals or groups of students. Hamilton et al. (2008) described self-study as “a look at self in action” (p. 17), proposing that self-study, autobiography, and narrative research exists at the “borders” of research methodologies. While literature on self-study as a research approach in nursing is limited, it is well established within education (Bullough & Pinnegar, 2001; Hamilton et al., 2008; Tidwell et al., 2009). Within education, self-study has been described as a way to examine and describe both practice and the space in which that practice occurs, including the tensions that exist between self, practice, and others who share the practice setting (Bullough & Pinnegar, 2001); and as an approach that “reveals the professional identity and knowledge of the researcher” (Hamilton et al., 2008, p. 21). In answering the question of when self-study becomes research, Bullough and Pinnegar (2001) proposed that “biography and history” must come together in such a way that the issue under consideration – that is the topic “confronted by the self” (p. 15) has a broader meaning or elucidates some aspect of a larger theory. Analysis in a self-study brings autobiographical, conversational, and written data “together in conversation” (Bullough & Pinnegar, 2001, p. 15). Self-study researchers may draw on a range of methodologies to guide their inquiry (Bullock & Ritter, 2011). For example, Bullock and Ritter used a blog as a way of communicating to one another and capturing their thoughts on becoming teaching educators in academia (Bullock & Ritter, 2011). Self-study in nursing has been described in relationship to clinical nursing education. For example, Woods (2021) used self-study to reflect on her role as someone thinking about her own professional learning as a clinical nursing educator, incorporating her experiences as an educator and school nurse.
Collaborative self-study, a self-study conducted by a small group of researchers, was used to examine the experience of teacher educators in academia by Bullock and Ritter (2011); we drew on their work in structuring our reflections on the integration of clinical practice with academic responsibilities. Our focus was the interrogation of our individual and collective experiences of that integration, rather than teaching or practice improvement. Thus, our goal was not to directly improve our capability as practitioners or educators, but to discern themes within our collective experiences, that might inform how professional activities are structured within academic nursing. Our study therefore extended the previously defined purpose of self-study within education around improving learning environments, to a goal of better understanding and potentially improving teaching and practice environments in nursing.
The boundaries between critical reflection, action research, self-study, and autoethnography can be challenging to discern. It could be said that we were involved in critical reflection-in-action (Rolfe, 2011b) as we explored the role of PhD-prepared NP within clinical and academic settings. Perhaps somewhat uniquely we were studying ourselves and our engagement within a particular context as individuals – NPs who also hold PhDs, who work predominately within the academy, but who also strive to maintain a clinical practice providing care to patients in our professional roles as nurse practitioners.
We used reflexive thematic analysis (Braun & Clarke, 2022) for coding of data and theme development; our use of this approach is detailed in the data analysis section.
Quality and Trustworthiness
To ensure trustworthiness, we drew on guidelines for self-study outlined by Bullough and Pinnegar (2001) who suggested that self-study research should prioritize an honest and unflinching approach to autobiography, the gathering of rich data, use of an authentic voice, and provide both “insight and interpretation” (p. 16) while paying attention to how findings are contextualized. These self-study guidelines include recommendations that themes be discernible, the research voice authentic, and the data robust enough to ensure that scholarly rigor is not in doubt (Bullough & Pinnegar, 2001). Bullough and Pinnegar noted that self-study research pertains to the “problems and issues that make someone an educator” (p. 17). The current study is concerned with what makes someone a particular type of educator – in this case someone who brings not only rigorous academic preparation, but also clinical experience and expertise to their academic role. The ability to practice clinically is fundamental to the NP role and enables the NP to most effectively help students embark on their own clinical training. Further, the issues and tensions explored around working as a PhD-prepared NP must be interpreted and understood within the context of nursing education, academia more generally, and current policy. Researchers must carefully balance their own autobiography and the research question. We each had our own story to consider; in essence four variations on the theme of how PhD-prepared NPs navigate the balance between clinical and academic work. Our findings are presented in conversational style; extended quotations are used to make our discussion visible, and to ensure that we provide the reader with insights into our thinking and process that are as close to inviting them into our group discussions as is feasible.
Consistent with guidance from Braun and Clarke (2021, 2022, 2023), we sought to ensure that data analysis was consistent with reflexive thematic analysis (RTA), and with an “artfully interpretative” approach (Braun & Clarke, 2023, p. 4). The underlying research values and assumptions we bring to this study are articulated below in our reflexivity statement. The themes outlined in this paper are interpretative, and we do not assume coding accuracy, recognizing that our individual and collective approaches are limited and defined by our experiences. An overview of final themes is provided in Table 2.
Although it is challenging to ensure diversity within a sample size of four, we included NPs working in both Canada and United States. All had held a full-time faculty position for between 1 year and 27 years and all continued to practice in a clinical setting (either primary care or a specialty practice). One of us identifies as male, and the other three as female, reflecting the general division of gender identity within nursing. Since we as authors are also study participants, member checking (Tracy, 2010) was an ongoing process from study conception through to analysis.
Reflexivity Statement
As researchers, we have varied expertise, including in our approaches to qualitative data analysis. We selected RTA as a flexible method that is compatible with a variety of methodologies (Braun & Clarke, 2006, 2022). We have approached this analysis as theorists within the constructivist paradigm, where meaning is socially constructed, considering how we, as participants in this self-study, make sense of our own experiences, within the context of work in the academy.
As a group of researchers and colleagues, we employed a collaborative self-study approach within a group context (Bullock & Ritter, 2011). The first author has participated in previous collaborative self-reflections, including a discussion of NP leadership during the COVID-19 pandemic (Whitfield et al., 2023). For the current study, we were interested in considering the implications, as we experienced and perceived them, of maintaining both an academic and clinical role; exploring how clinical practice fits within workload and academic promotion models; and considering how we as PhD-prepared NPs working in academia have integrated our clinical practice with academic work.
While we used RTA as a method, we are clear that this is a reflective paper, not a full qualitative study, although it may be used to develop future research. We adopted an inductive approach, coding the data as it appeared to us, without trying to fit to a particular pre-identified set of themes, while acknowledging that we bring certain preconceptions to this work, not least our collective interest in exploring this topic. We both acknowledge and celebrate our subjectivity as researchers. The themes presented here are a process of our active and deep engagement with the topic at hand, as both researchers and participants in this self-study.
Methods
Population and Sample
The population and sample for this collaborative self-study was a small self-identified group of PhD-prepared NPs. All of us were working clinically as nurse practitioners, and held tenured, or tenure track academic appointments. The initial informal discussions that provided the catalyst for this study occurred during an international nursing conference meeting in 2023. As a group of four we had not all worked on one project together; however, a variety of collegial relationships already existed within the group, meaning that we felt comfortable sharing information and ideas.
Data Collection
Data was generated in two ways – initial written email interview responses, followed by an in-person discussion during which we unpacked and elaborated on points raised in the written transcripts. Following preliminary discussions, the first and last author compiled a written list of questions that was circulated to all four authors via email (see Appendix A). As participants, we were asked to describe our current clinical and academic roles and career pathways. We were then asked to describe the benefits and challenges around combining clinical and academic responsibilities for themselves, and by extension their perception of benefits and drawbacks for patients and students. Finally, we were asked to identify any issues we considered to be important for consideration by policy makers and organizations. Reponses were uploaded to a password protected OneDrive folder (Microsoft 365) and shared with the full group for their review.
After review of the initial emailed responses, we met as a group for a 2-hour Microsoft Teams meeting to conduct a collaborative focus group in which we further explored ideas raised in written responses. This meeting was recorded, and an initial transcript was generated using Microsoft Teams software (Version 5.1.24.0). The transcript was reviewed for completeness and accuracy against the audio recording by the first author.
Analysis
During analysis, we followed the steps outlined by Braun and Clarke (2022), which include a process of becoming familiar with the data through a process of reading, re-reading, and taking note of any initial ideas; working systematically through the entire data set to produce initial codes; searching for themes; considering whether themes are workable; and generating a final list of themes (see Table 2). RTA has been proposed as an approach that allows for versatility, providing a way of identifying themes and patterns in the data and facilitating interpretation of the topic at hand (Braun & Clarke, 2006). In RTA, codes become the “building blocks of analysis” (Braun & Clarke, 2006, p. 229) and themes are actively constructed through the work of analysis by the researcher (DeSantis & Ugarriza, 2000). We also drew on the concepts of reflection-in-action and reflective thinking (Rolfe, 2011a).
Our data corpus (entire data) and data set (the data selected for analysis) for this project are one and the same (Braun & Clarke, 2006). Following review of all transcripts for accuracy and completeness, the first author was designated as the primary coder for the data, in line with best practice in reflective thematic analysis (Braun & Clarke, 2006). Coding was inductive, with iterative readings of the data; as such we did not use a pre-determined codebook and allowed codes and code labels to evolve as our thinking around the data developed. The first and last author collaborated to refine preliminary themes, determine final codes, and identify and describe initial themes. Individual elements of the coded data that might constitute a theme were uploaded into an Excel spreadsheet, which allowed us to continue our iterative approach during theme development, and to compare our work.
Ethical Considerations
This study was approved by the Queen’s University General Research Ethics Board (TRAQ #: 6041651). We held a collective discussion about confidentiality, and the need to consider how our current and past institutions might be represented both in conversation and in any publications. We sought to use our conversation to think in general and specific terms about the phenomenon of combining academic and clinical roles as PhD-prepared NPs. However, we were clear that our interest was not in directing criticism at institutions or individuals in any way, but rather in examining the combination of academic and clinical role responsibilities as one that offers both value and challenges for those who experience it.
Findings
Participants
The sample comprised the four authors for this paper, as detailed above and in Table 1. Three of us are tenured faculty in Canada, of whom two hold or have held administrative roles within university settings. One of us is a faculty member in their second year of a tenure track position in the United States, following 1 year in a clinical faculty role, also in the United States. At the time of data collection three were working in outpatient clinical settings and one was working in an inpatient clinical setting. Three of us were practicing within specialty settings; one was practicing in a primary care role, and one had previously done so.
Participant Characteristics.
Note. Role and years worked are reported as of August 2024. Percent of workload is based on hours allocated for clinical time based on a 40-hour work week and does not consider additional hours worked beyond 40 as part of academic or clinical responsibilities.
Themes
We identified five themes in the data. The first pertains to the ways in which clinical work was valued by PhD-prepared NPs, while the second focuses on how roles that combine clinical and academic responsibilities may be poorly understood or undervalued by colleagues in both settings, and perceived lack of credibility experienced by NPs. The third theme is focused on the ways in which teaching, research, and clinical practice were perceived as synergistically beneficial. The fourth theme is concerned with the challenges that exist around combining academic and clinical work, including time constraints, and the need to balance multiple responsibilities. The final theme is concerned with the lack of existing institutional frameworks to support combined clinical-academic roles – including how such roles are organized and considered within academic promotion standards and compensation models. Each theme is summarized in Table 2 and explored in the sections that follow.
Meaning-Based Interpretative Themes.
Value: Clinical Work Is Valued by PhD-Prepared NPs
Without exception, we valued our ability to participate in clinical work alongside research and teaching. As NPs working within the practice discipline of nursing it felt appropriate to us that we should continue to practice clinically. The appreciation for clinical work and the combined role extended to the benefits not only to our own professional lives, but to our students, patients, and the university more broadly.
Clinical work was personally and professionally satisfying and reinforced the foundations of what we as were educated to do as nurse practitioners; bringing us back to what it means fundamentally to be a nurse. The opportunity to spend some time practicing clinically was also valued as a counterbalance to academic responsibilities.
For some of us, having a balance between academic and clinical work increased our appreciation and enjoyment of our clinical roles.
Perceived Lack of Credibility: Combined Clinical and Academic Roles Are Poorly Understood and Undervalued
While a combination of clinical practice and academic roles served to reinforce our professional identities as both clinicians and academics, our perceptions were that academic and clinical colleagues often fail to fully understand a role that combines research and teaching with clinical work. This theme of a perceived lack of credibility points to structural and cultural barriers within both universities and the healthcare system.
As NPs, we sometimes felt as if we were not “real academic[s]” or like “second class citizen[s]” within our academic settings. “I was actually even not considered like a real academic because I came into academia like 20 years into my nursing career” (P-02). A combined academic and clinical role was sometimes not fully understood even by colleagues in the same nursing department: “How we are perceived by our colleagues as nurse practitioner faculty. We’re kind of like an anomaly, a different beast” (P-04). For several of us, this lack of understanding meant that we had to advocate and negotiate for a role that combined academic and clinical work within our departments both at hire and at promotion points.
The creativeness required of individual faculty when designing their clinical roles was perceived as different from the experiences of physician colleagues. Some expressed frustration that a combined role was difficult for our colleagues to understand, although similar combinations were accepted within medicine.
Lack of understanding was not limited to academic settings; within clinical settings, our academic work was often not considered relevant or understood. Language around professional titles could also create a disrespectful and problematic hierarchy, where academic doctorates were not respected within the clinical setting: “you took your doctor hat off as soon as you left the ivory tower” (P-02). From the patient perspective, academic work was likely not visible or deemed important, even though NPs felt that their academic work made them better clinicians.
However, despite the lack of understanding of NP/PhD clinical practice within clinical settings, there could be benefits as well. For example, P-04 noted that they have “found that being in the academy is beneficial for relationships in practice as well – my colleagues are quite keen on collaboration on projects and often ask for advice.”
As a group with significant clinical experience, our expertise was generally valued and sought after in the clinical setting. However, there was also concern that younger, less experienced NPs might struggle to find per-diem or part-time clinical work. Across the group, there was a sense that chance played a role in our securing clinical work opportunities: “I think like each one of us are in clinical roles, whether inside or outside our academic role, just out of serendipity like they didn’t, these roles weren’t created for us” (P-04).
Synergy: Teaching, Research, and Clinical Practice Are Synergistically Beneficial
Teaching, clinical practice, and research were perceived as being mutually beneficial, with each area informing and enhancing the others. An academic role, with a focus on research and evidence-based practice could inform provision of evidence-based clinical care. For example, P-03 noted that “My academic role pushes me to do more research in the clinical setting and bring forward evidence-informed care.” There was also the sense that the culture of ongoing learning in clinical work influenced other areas and responsibilities:
Clinical practice also directly informed programs of research: “My clinical experience has also helped shape and guide my program of research which has focused in the area of Indigenous Health” (P-02). In additional in informing choice of research topic, clinical work opened doors to new opportunities, and provided credibility with research participants:
We agreed that being practicing clinicians positively influenced our teaching, and the experience of our students who “often appreciated real-life examples and experiences in terms of situating their learning” (P-01). These benefits were seen as applicable for students at all levels – from undergraduate prelicensure nursing students to those in NP and PhD programs. Clinical practice was seen as informing and adding value to research and teaching, clearly situating faculty within the nursing profession, and providing real-life exemplars for nursing students in both clinical and research-based classroom settings:
Although NPs have clinical expertise, they often do not have formal teaching qualifications and must develop as educators in addition to maintaining their own content expertise. Faculty development was seen as beneficial in terms of mastering the role of educator, and all of us engaged in this in some way. P-02 described taking courses that were “really, really helpful and helped point out just how much I didn’t know and how much I really didn’t know how to teach.”
It was not only valuable to be able to incorporate clinical examples into our teaching, but also for students to see their faculty mentors actively engaged in clinical practice.
Synergistic work represents an ideal state whereby NPs can combine clinical practice, teaching, and research – with each area enriching the others. Such synergy also reflects a nimbleness – for example the ability to pivot to illustrate a teaching point with a clinical vignette.
Challenges: The Combination of Academic and Clinical Work Is Impacted by Time and Other Constraints
Overall, we agreed that having clinical time built into an academic role was important. However, competing demands could override the joys of synergistic roles. The fourth theme surfaces the challenges of sustaining combined roles and navigating structural or workload difficulties. For example, the perception was that often individuals end up working the equivalent of a full-time academic role in addition to their clinical practice. Where clinical time was included within workload, this was highly valued by NPs. For example, P-02 noted that they have “been able to have my clinical practice incorporated into my teaching workload which has made a huge difference in terms of time and ability to refocus on more scholarly pursuits.” However, protected clinical time could be theoretical in practice when the time exceeded what was budgeted. Administrative duties could add another level of complexity:
The pull of multiple responsibilities was exacerbated by combining clinical work with research and teaching. Increased research responsibilities meant less time to stay up to date with clinical knowledge, while clinical time could eat into time that would otherwise be spent on research and seeking research funding. It could also be difficult to task switch effectively, and especially difficult to put our clinical hats aside, for example when in the classroom with students.
There was concern that working clinically could either negatively impact research productivity or be perceived to do so. “it’s just been my experience and part of my trajectory and some of the roles I’ve taken on, but it’s by choice really” [that clinical work limits time for research and diminishes research productivity] (P-04). Taking on an administrative role within the university led to further challenges regarding time constraints and the balancing of multiple responsibilities.
The career trajectory for research, and for obtaining research funding was seen as relatively inflexible, with clinical work having the potential to disrupt that timeline in ways that had ongoing ramifications in terms of ability to receive grant funding.
There was also a perception that more research support could help to ameliorate some of these issues, and P-04 pointed to medicine colleagues who had a “research facilitator and a whole office full of research assistants and associates that collect people’s data, write their papers and those kinds of things. So, you know that, I mean, I realized that’s not in the realm of what we can have.”
Despite the challenges of balancing multiple responsibilities, part of our appreciation for the combination of tasks and work settings that working both clinically and academically provides, was the realization that full-time clinical work comes with its own set of stressors that can make working full-time in an NP role less desirable. These stressors included the medical documentation burden, reimbursement models that resulted in pressures to see more and more patients, as well as the nature of the work itself. One of us made a switch from primary to specialty care, in part because of the amount of continuing education required to stay current with a primary care practice and provide the best care and access for patients was challenging to integrate with other professional demands.
We also acknowledged the role of those in administrative roles in helping to support faculty. Availability of support for research activity is institution-dependent and may influence the experience of individual NP/PhD faculty. Challenges included conflicting/multiple responsibilities and time constraints.
Seeking Structure: Formal Models for Clinical-Academic Roles Are Lacking
A lack of models for combined roles meant that we sometimes had to exercise creativity and advocacy in how we balanced the different aspects of our professional lives. This final theme highlights the absence of institutional frameworks that support combined academic roles. While the need for frameworks may be organization dependent from both the academic and clinical perspective, we perceived benefit to structures that can protect and sustain our multifaceted contributions.
We debated whether it was important to be able to self-design and select our clinical roles, or whether these should be linked to our academic positions. There was recognition that each PhD-prepared NP will be different and bring a unique set of skills, expertise, and desire in terms of their ideal role: “In the ideal world we need to make the choices that are most appropriate for us [about] our clinical practice, whether we do it inside the academic sphere or outside” (P-04).
Opinions about compensation were mixed. For example, academic roles could be seen as having more potential for salary growth than clinical work, however it was the experience of some of us that, at least initially, moving from a full-time clinical role to academia, could entail a significant cut in compensation. In the U.S. context, P-01 expressed that clinical work had higher earning potential than an academic position and felt that this was a major disincentive to NPs thinking about entering academia. For those NPs working in Canada, some felt that academic positions paid better than clinical work or had an increased potential for advancement. Clinical roles could come with an expectation of compensation separate from the academic position or be subsumed within it. There was a desire to see NP compensation models mirror those in medicine, and a feeling that clinical work should generate additional compensation.
Discussion
This qualitative pilot study combined the use of two methodological approaches: collaborative self-study and reflexive thematic analysis. Our results consisted of five thematic foci: the value of clinical work; a lack of understanding of the PhD-NP role; synergistic connections between teaching, research, and clinical practice; challenges including time constraints and competing responsibilities; and the lack of formal models to guide the integration of the PhD-NP role into academic settings. Additionally, we were interested in using our data to inform the design of potential future studies looking at the PhD-NP role.
Clinical practice by NP faculty, whether they are PhD or DNP prepared, adds value for the NP themselves, for NP students, and for the broader academic institution and community (Gourley et al., 2024). There is little in the literature on any nursing faculty who hold tenure or tenure track appointments and practice clinically, and we did not identify any literature on NPs holding PhDs who hold tenure or tenure track appointments and practice clinically. To date, for our group at least, these roles have entailed creativity and a large degree of self-design. More models are needed moving forwards. We felt that nursing should include clinical practice not least because it is a practice discipline. Medicine was proposed as a model for combining academic and clinical roles, and for compensating those roles. However, it is also important to consider the challenges that nursing has historically encountered around being fully accepted as an academic discipline and around distinguishing the NP role from that of our physician colleagues. The issue of research support is echoed in a study by Candela et al. (2015), who considered how support from nursing school administration around research and grant seeking contributed to success with tenure and retention.
In the United States, where the DNP degree is increasingly common, and where clinical faculty are generally expected to practice, the combined role may be more accepted, although not always within a tenure track position. We do not intend in any way to dismiss the excellent work being done by clinical faculty who may hold either the DNP or PhD degrees. Rather, we seek to recognize that the inclusion of both RNs and APRNs as DNP and PhD-prepared nurses offers a richness of research and clinical expertise that benefits the academy, nursing as a discipline, and ultimately patients, families, and communities. It is vital that we continue to have NPs alongside their RN colleagues within the tenure track model.
Is it possible that the PhD-prepared NP may be destined to become a rarity within the United States? The DNP is a terminal practice doctorate; as such it seems possible that its wide adoption will result in decreased numbers of NPs who choose to pursue the PhD research doctorate, especially given the time and financial commitment required for NPs to attain both the DNP and PhD degrees. However, the PhD-prepared NP brings a particular advanced practice clinical perspective to research at the PhD level. The AACN has taken the position that nursing should develop PhD-prepared nurses who “reflect the broad diversity of society” (American Association of Colleges of Nursing, 2022, p. 1).
While the AACN 2022 statement on the Research Doctorate does not mention nurse practitioners, the organization cites the need to cultivate future faculty with both “advanced research and advanced clinical preparation” (American Association of Colleges of Nursing, 2022, p. 19). NPs are a large and growing subset of nurses. However, with a potentially declining group of PhD-prepared advanced practice nurses, we risk relegating the NP role to a silo within nursing research. To avoid this, we will need to encourage more NPs to consider the PhD degree, offer alternative pathways for NP students to choose either the DNP or PhD as their terminal degree, or include DNP nurses in tenure track research-based positions. We were not able to find data on the number of NPs pursuing PhD versus DNP degrees. However, it is logical to assume that fewer NPs are likely to pursue a PhD, at least in the United States. Although there are some DNP-PhD programs emerging, PhD nursing programs in the United States have seen flat enrollment (American Association of Colleges of Nursing, 2022). The full implications of these changes are beyond the scope of this pilot self-study; however, this is an important consideration for nursing research moving forwards.
While we did not discuss them in our pilot focus group, faculty-run clinical practices hold potential for ensuring that NPs who wish to practice part-time can do so in an environment where their academic responsibilities are considered, and where they can also directly provide clinical education as an embedded part of their clinical practice (Edwards et al., 2003). However, the logistics and financial implications of such faculty-owned practices pose significant challenges, especially for academic institutions that are not affiliated with hospitals or other direct service providers. We also did not directly address the NP transition to clinical practice, although our discussion uncovered some implications for newer providers, who may struggle to establish a part-time clinical practice.
The need exists for equitable faculty workload models across different types of nursing faculty (tenure track research-focused, clinical, teaching) (Boamah et al., 2021). There is some contradiction perhaps in seeing an embedded clinical component of academic roles as “imperative” and wanting to be receive compensation that is above and beyond an academic salary. The funding mechanisms for the NP/PhD role need careful consideration moving forwards, given their potential to impact sustainability for nursing programs as well as the university’s ability to recruit and retain nursing faculty.
Use of Self Study
It can be challenging to assess quality within self-study (Bullough & Pinnegar, 2001). Individuals engaging in any form of self-study must maintain a reflexive awareness throughout. The work we describe here was completed as a way of more formally engaging in learning around our professional practice as academics and NPs (Woods, 2021). Our findings are specific to us; however, we hope that they also contribute to the wider discourse about combined academic and clinical roles in nursing. Self-study is not about hypothesizing or producing generalizable results. Instead, the use of self-study provokes participants to “describe, understand, and interpret phenomena of interest” and to “document, analyze, and recursively interpret” what is learned during the process (Woods, 2021, p. 10). We have aimed to present our results in a way that is consistent with the meaningful and lively interactions we engaged in when collecting our data (Bullough & Pinnegar, 2001) – and invite the reader to consider this an invitation to join our conversation.
While our closeness to what we are investigating may be seen as a limitation, we propose that it is also a strength, allowing us to speak with authority about a phenomenon we have experienced first-hand over many combined years of professional work. The very closeness that could be limiting may also yield insights that might otherwise be unavailable to university and healthcare administrators.
Limitations
As a small group of NPs we comprise a limited sample, even for a pilot study. Additionally, we all work and practice within Northeastern Canada and the United States: three of us work within the same Canadian university system; one completed their doctoral training in Canada but has always practiced clinically in the United States and now holds an academic appointment there. Further study could usefully consider any geographic differences related to NP/PhD roles. Our results are preliminary and must be contextualized within healthcare and higher education financing and organization, which can differ on a national, regional, or organizational levels.
Conclusion and Recommendations
Combining the traditional academic roles of teaching, research, and service with clinical work, and/or with administrative duties demands a particular balancing act – and we experienced little in the way of formal preparation for this combined role. The richness of our self-study interview data, and the degree to which presentation of this work at conferences stimulated informal conversation and discussion suggests that further investigation into the NP-PhD role is warranted. Future research might include a larger study with a more diverse group of NPs with the goal of developing a model for the intersection of clinical and academic practice that can be used to guide tenure and promotion decisions. Such a study might include a full qualitative study with individual interviews and focus groups. Findings from any future study would need to be situated findings within the most current regulatory landscape, administrative priorities, academic and clinical practices, and fiscal constraints. The funding mechanisms for the NP/PhD role need careful consideration moving forwards, given their potential to impact sustainability for nursing programs as well as the university’s ability to recruit and retain nursing faculty. There is also a need for faculty collective agreements and clear mechanisms that reflect faculty clinical practice. The development of a model to guide clinical and academic practice would require sufficient flexibility to accommodate a variety of contexts and practice settings.
Footnotes
Appendix A
Acknowledgements
Material from this paper was included in an oral presentation at the 9th World Conference on Qualitative Research, 2025.
Ethical Considerations
This study was approved by the Queen’s University General Research Ethics Board (TRAQ #: 6041651).
Consent to Participate
The four authors are also the participants in this self-study and verbally agreed to participate.
Author Contributions
Conceptualization: MW, RW; Data collection: MW, RP, MS, RW; Writing, original draft: MW; Review for critical content, editing, manuscript development and preparation: MW, RP, MS, RW.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The dataset generated and analyzed during the current study are not publicly available due confidentiality concerns. De-identified data are available from the corresponding author on reasonable request.*