In this edition, Catherine Bishop, DNP, NP, introduces a series of articles about issues affecting oncology nurse practitioners. Here, Dr. Bishop describes how these advanced practice providers work alongside their physician partners to deliver patient care. Dr. Bishop is an oncology nurse practitioner at Johns Hopkins Kimmel Cancer Center at Sibley Memorial Hospital in Washington, DC.
Advanced practice providers (nurse practitioners [NPs], physician assistants, clinical pharmacy specialists, and others) are highly skilled professionals with advanced degrees who use their specialized training, education, and expertise to facilitate delivery of patient care. We are a growing group, with more than 234,000 NPs licensed in the U.S., Oncology NPs represent only a small portion of the NP population, approximately 1.2 percent, but we have grown in number and broadened our scope of practice over the past several years.1
The American Association of Nurse Practitioners (AANP) outlines a broad range of NP responsibilities, including assessing and evaluating patients, ordering and interpreting diagnostic tests, and initiating and managing treatments (including prescribing medications and controlled substances). Oncology NPs’ scope of practice depends on where we practice. Individual institutions, practice sites, and states each have distinct regulations that shape how we deliver patient care. These variations have given rise to questions about what an oncology NP truly is, what challenges we face in practicing to our full scope, and how our roles will continue to grow.
A Road Map to Oncology NP Practices
There are three practice models in which an NP can practice: full practice authority, reduced practice, and restricted practice.2 In each of these models, state practice and licensure laws regulate NPs’ levels of independence.
Full practice: This is the model recommended by the Institute of Medicine and National Council of State Boards of Nursing. State practice and licensure laws allow NPs to perform all the typical responsibilities under their own licenses. While this model does not require physician involvement, full practice authority does not mean oncology NPs practice without a physician partner. NPs are regarded as full members of the team who can see patients and make treatment decisions independently.
Reduced practice: Reduced practice restricts the ability of an NP to engage in at least one element of NP practice. State practice and licensure laws require a collaborative agreement with a physician for an NP to provide patient care (i.e., MDs/DOs discuss patient cases with NPs or meet with some of their patients).
Restricted practice: This model restricts the ability of an NP to engage in at least one element of NP practice. State practice and licensure laws require supervision, delegation, or team-management by an MD or DO to provide patient care. Physicians provide oversight of patient interactions and sign off on NP decisions. This type of practice model prevents NPs from providing full care to their patients and limits access to NPs.
Finding the Right Fit
While the full practice authority model is the preferred practice model for many oncology NPs, no matter the type of regulatory structure in which we practice, no one works in a silo. Collaborating with providers in many different disciplines is critical in providing the safest and best care for our oncology patients.
The benefit of our practice model is that it ensures continuity of care: My physician partner and I share a population of patients in an alternating-visit format. A patient may see the oncologist first, and then alternate visits throughout their oncology journey from the beginning of treatment through long-term follow-up. We are in daily communication about all our patients so, although they are being seen by different health-care providers, we are on the same page about a patient’s care, history, and ongoing cancer management.
This is critical to safe care, and our patients enjoy the fact that there are two providers who are fully involved in their care. Another aspect of our practice model that patients find reassuring is that, when one of us is away from clinic, the other is there to cover.
The independent model may not be appropriate for every oncology NP. In my opinion, it requires many years of experience and knowledge of the specific cancer and treatments involved to successfully care for patients with cancer. “Independent practitioner” is a role that NPs grow into as it requires the trust of your physician partner. Building this trust takes time and effort of both individuals.
Shining a Light on Oncology NPs
NPs and our professional organizations continue to advocate for lifting restrictions on NP practice and licensure laws preventing NPs from practicing to the full extent of their education and training.
For example, the AANP is supporting a bill working its way through Congress that authorizes NPs to order home-health services. Even in locations with full-practice status, such as Washington, DC, legislation doesn’t permit NPs to order at-home nursing care for Medicare beneficiaries without a physician’s signature.
In February 2018, a law passed in the District of Columbia allowing advanced practice registered nurses to sign, certify, stamp, or endorse all health-care related documents within the scope of their authorized practice. There are many individual state house bills being considered that would expand NP practice that ultimately improve access to many patients.
Our greatest challenge is the medical community’s lack of understanding of our role. I am fortunate to work within an institution that realizes our value and embraces oncology NPs, but we need to create an environment where oncology NPs can demonstrate their knowledge, skills, and value to the entire health-care community – administration, physicians, nursing staff, and patients.
- American Association of Nurse Practitioners, “NP Facts (Updated January 22, 2018).” Accessed March 7, 2018, from https://www.aanp.org/images/documents/about-nps/npfacts.pdf.
- American Association of Nurse Practitioners, “State Practice Environment.” Accessed March 7, 2018, from https://www.aanp.org/legislation-regulation/state-legislation/state-practice-environment.
Below are some tips for demonstrating the value of oncology NPs at your institution and beyond.
- Make your voice heard: This can mean writing for scientific publications or your institution’s newsletter to highlight the varied roles that oncology NPs fill. Also, volunteer for speaking engagements in the community or nationally.
- Educate colleagues about oncology NPs: Registered nurses, pharmacists, physicians, and administration might not understand the full scope of NPs’ practice, education, and oncology experience.
- Join professional associations that support NP practice: Societies such as the Oncology Nursing Society or the Advanced Practitioner Society for Hematology and Oncology provide educational resources specific to advanced practice providers.
- Gain respect: Work closely with the hospitalist group, consulting physicians, and emergency department physicians to foster positive relationships.
- Prove NP value: Make sure to get credit for patient visits in billing and reimbursement.
- Simplify your credentials so patients and others understand an NP is an advanced practice provider. Use your highest degree earned, then your role (for example: Mary Smith, DNP, NP; John Jones, MSN, NP; or Carly Simmons, PhD, NP). Avoid using RN if you practice as an NP because this is often confusing to many, including our patients.