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December 23, 2019
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APPs ‘integral,’ distinct part of the oncology workforce

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As advanced practice registered nurses, or APRNs — not doctors and not registered nurses — we often find ourselves straddling a chasm between the worlds of nursing and medicine.

Robin M. Rosselet, DNP, APRN-CNP/CNS, AOCN
Robin M. Rosselet

We need to step away from this chasm and describe who we are; we are APRNs who practice medicine with all the values we learned as nurses. If we had been told in graduate school that we would be practicing medicine, I think we could have wrapped our heads around this a lot sooner.

Creating an engaged workforce

The U.S. is facing a national physician shortage estimated to exceed 100,000 physicians by 2030. Meanwhile, the opioid crisis looms across the country, creating a greater need for providers, particularly in rural areas. Further, ASCO projects a shortage of over 2,200 oncologists by 2025, amid a 40% increase in overall demand for oncology services.

Conversely, we have rapidly growing number of nurse practitioners (NPs), who represent only one subset of all APRNs. There are more than 270,000 licensed NPs in the U.S. and, as we will be standing in the gap to provide both primary and specialty care medicine, it is imperative that APRN leaders get the onboarding of new APRNs right.

According to the American Association of Nurse Practitioners, 87.1% of NPs are educated in primary care, yet they are increasingly being used in specialty care. The 2011 Institute of Medicine report “The Future of Nursing” endorsed nursing practice at the full scope of education and specialty training.

As an APRN leader, leading a rapidly growing workforce of NPs, clinical nurse specialists and physician assistants in oncology, I became convinced I needed to abandon the old-fashioned 12-week orientation and think innovatively about how to create a highly competent and engaged oncology advance practice workforce.

Taking a ‘big leap’

As I hired new graduates who had trained in either primary care or acute care, I invited them to embark upon a career they were not trained for: oncology. They were making an incredible journey from either practice as an RN, or never having practiced before, to practicing medicine. This is a big leap.

As I scanned the worlds of nursing and medicine, I noted that nurses had transition-to-practice programs (RN residency) and, likewise, physicians who wanted to work in oncology went through oncology training programs (fellowship). Based on these models, I and a team of colleagues at our institution developed an APP oncology fellowship program, which was designed to train APPs, after receiving their master’s degrees, to practice oncology in the ambulatory, acute or critical care settings based on their underlying certification.

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Seven years into this journey, we have an Oncology APP Fellowship, which is accredited with distinction by the American Nurses Credentialing Center and has graduated 64 fellows.

This year-long fellowship trains APPs to practice at the full scope of their license as highly skilled and competent members of our interprofessional oncology health care team. We have hired 95% of our fellows with an all-time low turnover rate, suggesting we have a high-quality and engaged oncology APP workforce.

We concentrate on developing their specialty knowledge in oncology with the goal of becoming Advanced Oncology Certified Nurse Practitioners (AOCNP®) by the end of the fellowship. This advanced knowledge comes along with 2,000 additional clinical hours with a number of our APP experts with a concentration on improving their physical exam, assessment, diagnosis and treatment planning for the oncology patient in a variety of settings. The fellows rotate through both medical and surgical services and both inpatient and outpatient settings with a goal of understanding the breadth of oncology before subspecializing.

Those 2,000 clinical hours set the fellowship training apart from standard onboarding, as most NP programs consist of 500 to 600 hours which, in my opinion, is not nearly enough to master the level of practice required particularly in a specialty practice. We also add in training in resiliency, stress management, ethics, critical thinking, decision-making and interprofessional practice.

The evidence shows that transition-to-practice programs and mentorship lead to safe care, improved retention, enhanced knowledge transfer and an estimated annual cost savings of approximately $300,000 per APP not lost to turnover.

I am constantly asked why RN orientation is different from that of the APP. My response is that we are APPs and, thus, our role is very different and requires a different level of training.

APPs provide and coordinate patient care — both primary and specialty health care — and we diagnose and treat acute and chronic illnesses. We perform physical exams, order diagnostic and laboratory testing, develop differential diagnosis, make treatment plans and prescribe medications.

APPs are an integral part of the health care workforce across the U.S., but we deserve to be recognized as a profession, not an extension of nurses or physicians.

References:

Alencar MC, et al. Clin J Oncol Nurs. 2018;doi:10.1188/18.CJON.142-145.

American Association of Nurse Practitioners. NP fact sheet. Available at: www.aanp.org/about/all-about-nps/np-fact-sheet. Accessed Nov. 27, 2019.

Association of American Medical Colleges. Recent studies and reports on physician shortages. Available at: news.aamc.org/medical-education/article/new-aamc-research-reaffirms-looming-physician-shor/. Accessed Nov. 27, 2019.

Barnes H. J Nurse Pract. 2015;doi:10.1016/j.nurpra.2014.11.004.

Bazzell AF, et al. J Nurse Pract. 2018;doi:10.1016/j.nurpra.2017.12.008.

Beaver C, et al. (2016). Oncology Nurse Generalist Competencies. Pittsburgh, PA: Oncology Nursing Society.

Benner P, et al. (2010). Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Jossey-Bass.

Cohen S, et al. (2007). Oncology Nurse Practitioner Competencies. Pittsburgh, PA: Oncology Nursing Society.

Institute of Medicine. (2011). The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press.

Klein T and Lugo R. J Nurse Pract. 2018;doi:10.1016/j.nurpra.2018.08.021.

Mackey H, et al. Clin J Oncol Nurs. 2018;doi:10.1188/18.CJON.516-522.

Nevidjon B, et al. J Oncol Pract. 2010;doi:10.1200/JOP.091072.

Spector N, et al. J Nurs Regul. 2015;doi:10.1016/S2155-8256(15)30003-X.

For more information:

Robin M. Rosselet, DNP, APRN-CNP/CNS, AOCN, is director of advanced practice providers at James Cancer Hospital and Solove Research Institute and associate professor of practice at The Ohio State University College of Nursing. She can be reached at 460 W. 10th Ave., Room b160b, James Cancer Hospital, Columbus, OH 43210; email: robin.rosselet@osumc.edu.

Disclosure: Rosselet reports no relevant financial disclosures.