The Nurse Practitioner’s Role in the Practice
Rewind about 5 years to 2010, and consider a few of the things that typically occurred in a medical practice: an infusion nurse sitting in the hall outside of an examination room, waiting for the physician to come out to answer a question about a patient. A triage nurse is lingering outside the exam rooms waiting for the physician, and a stack of paperwork is sitting on the physician’s desk, awaiting completion. In another snapshot, tests for the physician to review remain untouched until he or she has time—usually at the end of the day—to specify to staff members what needs to be done.
Fast forward to the present, and all of that has changed. In a growing part of oncology practices, nurse practitioners (NPs) are applying their nursing expertise to both clinical and management roles, and helping to streamline procedures and develop more efficient protocols in oncology care. When an NP is on vacation, you can be assured that a doctor will be looking for him or her, because the doctor is dealing with patient care issues that the NP has largely assumed. In our practice, NPs are critical members of the management and patient care team, serving as physician extenders by contributing essential skill sets and performing key roles (Table).
The concept of physician extenders in an oncology practice has evolved over time. More than 10 years ago, Elaine Towle, CMPE, spoke at a medical society meeting about how an NP and physician assistant (PA) were being used at her New Hampshire practice. The team was using the PA and NP as extenders not only to see patients during follow-up visits, but to supervise chemotherapy administration. Payers were reimbursing the practice for these visits, and the practice was able to address chemotherapy scheduling problems that occurred when the doctor was not present in the suite. The concept intrigued me, and I began an investigation into how we could use an NP in our own practice.
Initially, the use of physician extenders was not a concept that interested our physicians; it was not until we completed an analysis of how an NP could benefit the practice that there was interest. We learned that an NP could also provide coverage for the infusion room. Our practice has multiple satellite offices, and the ability to provide infusion services on days when a physician was not in the suite was of interest from the standpoint of continuity of care, as well as from the standpoint of improved staff efficiency. The year was 2002, and at that point in time, the physicians were not keen on having the NP see their follow-up patients, but they were very interested in expanding the number of days that chemotherapy was administered. With the NP in the office, this became possible. So the question was where and how do we start?
We needed an NP who would have immediate credibility with the doctors. Fortunately, one of my nursing school colleagues was the ideal candidate. Not only was she an NP, but she also came with intensive care nursing experience. She had set up the oncology unit and infusion center at one of the hospitals she worked at, served as manager for the service, and became the clinical nurse specialist. In that role, she developed programs and trained new staff nurses. She then went on to become an NP, moving from oncology to family practice.
Even though she had been out of oncology for a few years, she had credibility among the physicians and nurses in the practice. With this one hire, we obtained an oncology provider who was experienced, and who had management and program development expertise. The real challenge was to convince her that she was the ideal candidate to develop this new role in a practice. Her management and program development skills were critical to the implementation of the NP role; however, there was no job description, no real definition of what the role would be, and no guarantee that it would continue. It was a gamble on her part. All she had was my belief that the oncology NP was going to play a significant role in the future of cancer care. I am grateful every day that she decided to take the chance.
The physicians agreed to fund the position in 2002, and she was hired. She started in a clinical role, primarily covering chemotherapy infusions when the physicians were not in the suite. She was not assigned to one specific office, and moved from office to office. In doing so, the registered nurses (RNs) in those offices learned to rely on her to help them with all sorts of patient care issues. Fortunately for us, our NP was someone who did not require a lot of direction and who was very comfortable in all of our offices. Although at times she got tired of moving from one office to another, she did not need to be assigned to just one office. She rarely worked in an office for the entire day, and working in a single office for a whole week simply did not happen. She was the plug person, filling in when a doctor was on vacation or covering a morning or afternoon when a physician was not going to be in the office. Because of her, we were able to open up additional office hours, which greatly enhanced our ability to provide consistent care to the patients. Often, she would be working in an office but get a call from another office about a patient care problem.
Initially, our NP did not have a full schedule of patients, but that started to change as several physicians began to realize that she could provide excellent follow-up care while they focused on new consults and patients who needed changes in therapy. With this came the realization that we could use more help in the NP role. We began adding NPs to work with physicians in our satellite offices, and with these additions came differentiation of the NPs’ roles in our practice (Table). Today, we have NPs providing clinical services and assuming management responsibilities in our operation. We also have NPs who are responsible for developing and implementing new services in the practice. This diversity in the role is attractive to NPs who have interests beyond clinical services.
The clinical role is the foundation of the NP’s role in our practice. One of the benefits of having a diverse group of NPs is the various backgrounds and experiences they bring to their positions. We have several NPs with critical care backgrounds, which is useful when there is a crisis in the infusion room. We also have NPs with a strong primary care background, which is helpful when they are managing the comorbid conditions that our patients often have. The family practice background helps NPs develop a schedule that is efficient, but also provides enough time for question-and-answer sessions with patients and their families. We have an NP who has a palliative care background, which is helpful in the development of end-of-life programs.
The clinical role is office-based as well as hospital-based. We have several NPs who have a combined hospital-rounding role and an office schedule. For the NPs in this role, continuity of care is important. These NPs see patients in the hospital and then can see them during their posthospital visits to the office. It is an important care coordination and navigator function.
The NPs who are exclusively office-based are important navigators of care within the office. They communicate with the doctors about the patient’s plan of care, and then work with the staff to ensure that the plan is implemented. These NPs handle triage in the office, and are the go-to people for all patient care issues. The physicians have noticed a significant reduction in the number of interruptions in their schedules. The NPs review test results and consult with physicians as necessary prior to communicating with the patients and their families. In Ohio, where our practice is based, NPs can order select narcotics, so pain management and other supportive care medications are ordered based on patient needs. With the addition of an in-office dispensary, the NPs are able to provide supportive care medications needed for a regimen at the time of the patient’s appointment. Patients leave the office not only with information, but with medications needed to support them at the start of their treatment plan.
Another important clinical role is the hospital-based NP. NPs who make hospital rounds function as hospitalists for the practice in hospitals with which we are affiliated, and collaborate with the rounding physician to manage new-patient consults, orders, and assessments for the practice’s patients. The transition of care from office to hospital, hospital to office, or hospital to home or hospice is handled by this NP. In recent months, an RN has started providing rounding support as well.
Another responsibility that the NPs assume in the offices is that of triage. In the past, this was done by RNs; however, an evaluation of how to improve productivity and reduce physician interruptions led to us changing this to an NP responsibility. This is an important responsibility, and provides substantial support to the office phone staff. Further development of the role will include identifying what has been directed to an NP that could be more efficiently handled by an RN or licensed practical nurse.
Not everyone is content with a purely clinical role. For some NPs, management opportunities are essential for their growth and development. Managing a large group practice with multiple satellite offices is difficult without assistance. Our NPs provide support as office supervisors, and each supervisor is responsible for the personnel management in his or her office. NPs who assume this responsibility are in a unique position to improve patient flow and productivity.
These supervisors need support from an experienced manager, and because of her past experience, our very first NP assumed the role of the chief nursing officer and NP team supervisor. Not only did she have the required management experience, but she also understood the needs of different members of the staff. She conducts quarterly NP meetings, hires and evaluates new NPs, and ensures that a proper orientation is completed and that areas for development are addressed. She is also responsible for the productivity of each NP, and provides feedback to each NP related to this. In this role she is also responsible for the clinical operations of the practice. She has been instrumental in the initiation of the American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) audits, QOPI certification and recertification, and planning for certification by the National Committee for Quality Assurance as a Patient-Centered Specialty Practice.
Although management is not for everyone, some NPs are able to use their skills and expertise to serve as role models for all staff members in a practice. These NPs see needs and are interested in developing services to meet those needs.
One of our NPs was very interested in using continuous quality improvement processes to begin changing the way we deal with depression and patient distress in the practice. She became involved in a Michigan Society of Hematology and Oncology–sponsored quality initiative to ensure that we were conducting initial and ongoing assessments of the emotional status of our patients. Drawing on her skills as an educator, she evaluated the assessment tools, conducted training sessions with staff on how to administer the tool, and oversaw the implementation of this important component of care. We were ahead of the curve with this idea. Today we have survey tools on many of our charts, and we use the data to assess the need for intervention. It is nice to see that other organizations today understand the importance of mental health, distress screening, and the impact of depression on response to therapy.
Another area where the NPs help in program development has been with the initiation of our in-office dispensing service. The NPs helped outline the way oral chemotherapy dispensing would be monitored, and set up patient teaching visits. These visits are initiated for every patient before the start of a new chemotherapy order, whether it is an injected or oral medication. The NP reviews the treatment plan, answers any questions the patient and family may have, orders supportive care drugs, and provides the patient with treatment and follow-up visit appointments.
The NPs also integrated patient follow-up as an important component for ensuring patient compliance with an oral treatment plan. This was done before we had a dispensing pharmacy. The processes that were initially set up for interacting with a specialty pharmacy have now been integrated into our own dispensing process. Again, we have seen that we are ahead of the curve with regard to care management of these patients. During our QOPI recertification process, our surveyor complimented our practice’s process, and we were asked to be a resource for other practices.
The addition of NPs has added important elements to improve practice operations. They provide clinical services in our offices, and see patients at routine follow-ups and in the infusion suite. They are nursing leaders, provide direction and support to the clinical staff, and serve as role models throughout the practice.