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|Advanced Practitioners in Oncology: Meeting the Challenges|
A study commissioned by the American Society of Clinical Oncology (ASCO) projects that the demand for oncologist visits will increase 48% by the year 2020, but the visit capacity is expected to increase by only 14%. Many reasons are cited for this shortage, including aging of the population, increasing number of cancer survivors, and expanding treatment options that require an increased frequency of visits. One of the proposed solutions to meet this challenge is the increased use of nurse practitioners (NPs) and physician assistants (PAs). Hereafter, this group of NPs and PAs will be referred to as advanced practitioners, or APs. As integral members of the multidisciplinary team, oncology pharmacists can also be considered APs.
Advanced practitioners are poised to be a vital part of this current and impending health care crisis. APs provide quality, safe, and cost-effective care. To meet the projected demand for oncology services in 2020, it will be essential to utilize APs to their fullest scope of practice, to expand the AP workforce, to accurately define the AP role, and to form creative collaborative practice models. The current challenges facing oncology and health care seem vast, but these challenges may be viewed as an opportunity for the maturation of the AP role.
Oncology PAs, CNSs, and NPs share many professional roles and challenges. Umbrella terms such as midlevel providers or physician extenders are often used to collectively identify these advanced practitioners. Such terms tend to trivialize the significant and unique contributions of APs to the health care team. Multiple studies show that APs provide excellent, cost-effective, and safe care complementing the care given by other members of the health care team.
APs have prescriptive privileges in every state. In fact, in a number of states, advanced practice nurses have no requirement for any physician involvement. The rest of the states require written documentation of physician involvement, which may entail collaboration, supervision, authorization, delegation, and/or direction. PAs are authorized to prescribe in every state as per physician delegation. PAs, CNSs, and NPs have other common and distinctive professional elements as well.
One of the common challenges of APs in oncology is the lack of an oncology-specific educational background. Most advanced practice nurses are educated in a primary care setting such as adult, family, pediatrics, women’s health, gerontology, or acute care populations. Very few advanced practice nurses complete an oncology-specific graduate program. However, advanced practice nurses may receive advanced board certification in oncology, indicating additional education and clinical practice expertise in an advanced oncology role. Physician asistants are trained in internal medicine and required to pass a national certifying examination administered by the National Commission on Certification of Physician Assistants before they can practice. Physician assistants do not have set standards for specialty practice, and specialty credentialing and certification are controversial in the field.
The lack of available graduate and postgraduate oncology educational programs creates an educational gap for the many new APs in oncology. This educational gap, in turn, increases the amount of time required for the AP to become a fully competent and independent oncology practitioner. Both PAs and advanced practice nurses report that their current oncology clinical skills and knowledge were obtained most often via mentoring by a collaborating physician or through self-study.
Scope of Practice
The oncology AP also faces challenges regarding scope of practice. The PAs scope of practice is defined by the education and experience of the individual as well as by state law, federal policy, and physician delegation. Physician delegation may vary widely between practices, but it is the largest determinate of PA scope of practice. The advanced practice nurse scope of practice is determined by each state’s nurse practice act. Many states allow independent practice (no requirement for any physician involvement). Other states require a range of physician involvement, such as collaboration, supervision, authorization, delegation, and/or direction. This variation in advanced practice nursing scope of practice limits the mobility of the practitioner and can create confusion among health care providers.
Another challenge to oncology APs is the lack of a clearly defined role. Oncology APs are delivering safe, quality care in numerous oncology settings, spanning the cancer trajectory from high-risk cancer clinics to hospice and palliative care. Responsibilities may vary from traditional (such as patient education and symptom management) to advanced (new consults, ordering chemotherapy, or performing invasive procedures). The range of tasks performed by the oncology AP is immeasurable, but some unique settings in which oncology APs are working include interventional oncology practices, cancer genetics, prostate cancer clinics, and radiation oncology.
Workforce studies may underestimate the role of the oncology AP. Work performed by the AP may be attributed to a supervising physician if data is not collected properly. Practices often do not track AP productivity accurately, particularly when billing “incident-to” physician services. Prescriptions written by the AP are often deemed that of the physician and reported accordingly. More extensive research is needed to delineate the responsibilities, workload, productivity, and efficiency of the oncology AP. Defining the role of the oncology AP can increase efficiency of practice models and improve health-care delivery.
The oncology team of physicians and APs work together in differing practice models. New, innovative model development is needed to increase productivity and improve patient outcomes by delivering higher levels of care. New models should require each team member to function at their highest scope of practice and expertise and to relinquish tasks that a lesser-trained team member could perform. Effective utilization of support staff, administration, and electronic tools can improve efficiency and effectiveness. This will require effective collaboration among all team members. There are few published articles on AP/physician collaborative models, and those that are available are primarily found in nursing journals.
Solutions to the challenges facing health care in general and oncology specifically will come from within the multidisciplinary health care team. The AP can and should have an integral part in both elucidation of the issues and formulation of the remedies.
Recruitment of APs, registered nurses, and physicians to oncology and oncology education is fundamental to addressing the health care shortages. Successful recruitment strategies can be examined, and similar strategies can be designed for oncology. Recruitment can begin as early as junior high school or high school by introducing students to the oncology field through lectures, field trips to cancer centers, internships, professional job shadowing, and partnering with student organizations at charitable cancer events. APs can contribute to oncology education by serving as adjunct faculty for undergraduate and graduate students. Mentoring and precepting students will yield long-term rewards to the oncology field.
Retention of Clinicians
Retention of oncology health care professionals is an integral component of solving the health care shortage crisis. Improving the work environment by mutual respect between team members is often more effective than increased salary. However, salary remains a factor that affects retention as well. Adequate orientation for new employees, ongoing education, coaching and mentoring programs, and flexible work schedules are other factors that contribute to employee retention. Additional innovative ideas are needed.
Education and Training
Education and training for the AP who does not have an oncology background is essential. Oncology providers (including physicians, APs, pharmacists, and facilities) can work with medical, nursing, and pharmacy schools to ensure that oncology is a greater part of the general curricula. Development of in-house educational and preceptorship programs is cost-effective and ensures that trainees are oriented to the institution or facility culture. Oncologists who allow time for adequate mentoring of APs will find that the AP will be prepared more quickly for autonomous practice. Creative mentorship initiatives are needed. Experienced APs can fill the mentor roles in place of physicians and serve as a resource for the novice AP. Studies show that oncology APs frequently use self-study as a method of becoming comfortable in their role. Novel self-study models, utilizing electronic resources, may be designed and distributed to the new oncology AP. Contributions from both medicine and nursing are essential to a comprehensive educational program.
Mentorship also comes in the form of networking. Oncology APs should be encouraged and supported in participation with professional societies including, but not limited to, ASCO, the Oncology Nursing Society (ONS), ONS special interest groups, national PA and advanced practice nursing organizations, as well as local professional societies. Financial support and time allowances will be necessary.
Oncology APs must be allowed to function at their highest scope of practice. Recognition of and respect for the training and skills of each team member will enable the most effective delegation, the highest level of care, and the best patient outcomes. Efforts to limit a discipline’s scope of practice should not be supported by any health care team member, as these efforts are divisive and impede collaboration to develop solutions to the health care crisis. Data from the National Practitioner Data Bank and the Healthcare Integrity and Protection Data Bank illustrate that states in which advanced practice nurse practice autonomously do not have higher rates of malpractice reports. It is necessary to recognize that pioneering effective new models of care delivery are, in essence, a culture change. Flexibility, tolerance, and open-mindedness of all team members will allow the smoothest, most efficient changes to occur.
Oncology APs must be legislatively savvy and active. Potential legislation must be carefully examined for language that is inclusive for all health care providers. The biggest obstacle to the most effective utilization of APs is the lack of full practice and prescriptive authority. Currently, the scope of practice, licensing, prescribing authority, and supervision requirements of APs vary based on state law. For advanced practice nurses, implementation of the Consensus Model will standardize education, certification, accreditation, and regulation across the United States. Legislative advocacy is an important function of national AP associations. Through membership in these organizations, APs can support legislative activities and obtain information about legislation affecting clinical practice.
It has been said that, “if you are not at the table, then you are probably on the menu.” Oncology APs are an essential component of the solution for the US health care crisis. Advanced practitioners cannot just settle for being “at the table,” but must set the table and plan the menu! At this crucial moment in time, current APs can position future generations to reflect that their success and the resolution of a crisis in health care was created by what APs did today! Advanced practitioners must engage in arenas outside of their current comfort zones. Now is the time, not tomorrow or next week. Proactivity, not reactivity, is the key. So, forego the status quo…and show up, stand up, and speak up.
Adapted from "Advanced Practitioners in Oncology: Meeting the Challenges" by Wendy H. Vogel, MSN, FNP, AOCNP® (J Adv Pract Oncol 2010;1:13-18 | DOI: 10.6004/jadpro.2010.1.1.2)
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