Special Issue: Oncology Nursing
Nurses and Physicians Collaborate to Improve Cancer Care
In the suburban St. Louis oncology practice of Dr. John Wilkes and his colleagues, every patient starting a new treatment regimen meets with a nurse practitioner (NP) for a roughly hour-long education session.
“That’s my first opportunity to introduce myself to patients…and establish a relationship with them, so that when I see them while they are in treatment, they already know who I am and that I am part of the physician’s team,” explained Melanie Maze, one of two NPs in the office.
NPs “are hands on in every facet of our endeavor,” Dr. Wilkes said. They help with patient care, develop survivorship care plans and review them with patients, serve as intermediaries between the physicians and other nurses in the office, and supervise the treatment room, where nurses administer chemotherapy and biotherapy.
Collaborative working relationships like the one between Maze and Dr. Wilkes, which are often legally cemented by a collaborative practice agreement, are not unusual.
And as the aging U.S. population and growing number of cancer survivors increase the demand for oncology services, oncologists are looking to advanced practice nurses—NPs and clinical nurse specialists—to help meet that demand. These nurses are joining forces with oncologists in community-based practices as well as in hospitals and academic medical centers to perform a variety of roles.
Advanced practice nurses not only help ease physicians’ workloads but also bring complementary skills, abilities, and perspectives to the table, adding breadth and depth to patient care, noted Georgia Decker, an NP in Albany, NY, and a past president of the Oncology Nursing Society (ONS).
“The delivery of cancer care has gotten very complicated, and it takes a whole team to deliver modern, high-quality care,” said Dr. Michael Goldstein of Beth Israel Deaconess Medical Center, who co-chairs the American Society of Clinical Oncology’s (ASCO) Workforce Advisory Group.
Easing Workforce Shortages
More than half of 226 oncology practices surveyed in the ASCO Study of Collaborative Practice Arrangements reported that they employ NPs or physician assistants (PAs), jointly known as nonphysician practitioners. (The study did not distinguish between NPs and PAs.)
The study, the results of which were reported last September in the Journal of Oncology Practice, showed that, in community oncology practices that employ NPs and PAs, patient satisfaction was universally high and physician and nonphysician provider satisfaction was generally high. The study also found that practices in which NPs or PAs worked with all physicians in the practice and saw a wide variety of patients had higher productivity.
—Dr. Michael Goldstein
ASCO’s interest in examining collaborative practices stemmed from the organization’s 2007 study that forecast a significant shortage of oncologists by 2020.
“One of the myths that the [collaborative practice] study dispelled was that patients may not be satisfied with NPs providing oncology care as part of a physician-NP team,” commented Dr. Dean Bajorin, an oncologist at Memorial Sloan-Kettering Cancer Center who co-chairs the Workforce Advisory Group with Dr. Goldstein.
A Win-Win for Patients and Physicians
“Collaboration improves patient care in a number of ways,” said Decker, who sees cancer patients and survivors in a primary care practice and also has a private nursing practice.
Oncology nurses are trained “at the bedside, and they pay very close attention to patients’ physical, spiritual, and emotional needs in ways that medical oncologists are not as focused on at times,” Dr. Wilkes noted.
And, whether in a community practice, hospital, or academic medical center, nursing professionals tend to play a greater role in communicating with patients and patients’ family members than physicians do. “Generally speaking, especially with the shortage [of oncologists], physicians are relying heavily on nurses and advanced practice nurses or PAs to keep that line of communication open,” said Decker.
Communicating with patients and their families is central to Karen Stanley’s job. A clinical nurse specialist and former ONS president, she manages the pain and palliative care service at Stamford Hospital in Connecticut. “By spending time with the patient and their family, I can learn things that are critical to making difficult decisions,” she explained.
At Memorial Sloan-Kettering, where Dr. Bajorin works, oncologists and patients alike have noted the benefits of having NPs on the inpatient bone marrow transplantation teams.
“Because NPs have an intimate knowledge of the treatment protocols and the patients, it provides better continuity of care,” Dr. Bajorin said. “Figuratively speaking, the NPs are there with their fingers on the patient’s pulse on an ongoing basis. And they are superb at transitioning and coordinating care to the outpatient setting.”
Maze pointed out that collaborative practice arrangements also offer financial advantages to oncology practices by freeing up physicians “to do things that have a financial impact on the viability of the practice,” such as seeing new patients or going to the hospital to consult on a case.
“There’s no question,” Dr. Wilkes confirmed, that collaborative practice arrangements allow physicians to see more patients. “But that can’t be the primary goal.”
Recipe for Success
The ingredients required for successful collaboration between oncologists and advanced practice nurses are not unlike those needed for a successful marriage. “Like any relationship in life, it’s about communication,” Dr. Wilkes said.
Mutual trust and respect are also critical. “The physician has to trust that you know what you’re doing, and give you the ability to practice fully within the scope of your practice,” Maze said. In a successful collaboration, Decker elaborated, “there is recognition of individual practitioners’ strengths and the ability to put those strengths into action.”
“[Having] not only respect for the other person as a person, but also respect for the skills that they have and the knowledge that they bring to the table” is important, asserted Stanley.
A close working relationship between the two providers is key, Dr. Wilkes emphasized. “If an NP and physician have a collaborative practice, but the patient is not routinely seen by both members of the practice, there is a potential for miscommunication,” he said.
A Need for More Training
While oncologists are looking to NPs to help fill gaps in delivering care, the advanced practice nursing field, too, is contending with shortages.
On top of a general shortage of NPs, few formal training programs in oncology exist for advanced practice nurses. (The largest such master’s degree program is at the University of South Florida.) “One of the challenges I see is that [oncology] NPs are receiving their education in an almost apprentice-like fashion in the community” from the physicians they work with, Dr. Bajorin noted.
Although ONS offers certification as an Advanced Oncology Certified Nurse Practitioner, most state boards of nursing do not recognize such certification. “Many states want NPs certified in the broader areas like acute care, rather than in subspecialties like oncology,” said Dr. Anne Belcher, an associate professor in the School of Nursing at the Johns Hopkins University.
That’s one of the chief reasons that master’s-level oncology nursing programs are scarce, explained Dr. Joyce Dains, who directs a post-graduate oncology fellowship for advanced practice nurses at the University of Texas MD Anderson Cancer Center. With only two or three fellows admitted each year, the application process for the year-long program is very competitive.
Financing such programs can be difficult. “The vice president for nursing [at MD Anderson] feels very strongly about having this education program available, so she has funded the fellowship” each year since it began in September 2006, Dr. Dains said. MD Anderson is also thinking about starting a residency program in oncology for advanced practice nurses hired to work at the cancer center, she continued.
Yet another challenge, Dr. Belcher noted, is that “there aren’t many oncology NPs to teach oncology NPs.” Most people with such advanced training prefer clinical practice to full-time teaching and can earn much more money in a health care setting than as faculty members, she explained. “It’s going to get worse with the graying of the faculty,” she concluded.
And the shortage of oncology-trained NPs could hinder the expansion of collaborative practice arrangements. “As much as we like the collaborative practice model, and as much as it works well, if we don’t have enough NPs to do it, it’s a moot point,” Dr. Goldstein said.