There is no doubt that managed care is changing health care and the practice environment of all health-care providers. As Baird states, The economics of health care will probably exert a greater influence on the future practice of nursing than any other single factor.
McDermott Blackburn provides a comprehensive overview of the evolution of the roles of advanced practice nurses (APNs), particularly in oncology, within the context of a health-care market increasingly dominated by managed care. She aptly describes the increased attention of organizations and resultant redirection of APN functions. She also highlights the impact of the decreased availability of house staff on the duties of APNs, particularly nurse practitioners (NPs), who have had to take on many of the patient care responsibilities formerly assumed by physicians.
Oncology Clinical Nurse Specialists as Case Managers
These trends have created the need in many organizations for oncology APNs with a practice focus and/or expanded knowledge and skills different from those required for the traditional APN rolethe oncology clinical nurse specialist (OCNS). The primary functions, historically, of OCNSs have been to develop, implement, and evaluate programs/standards for quality care, educate staff, and plan and provide nursing care to complex patient populations. In addition, educational preparation in the subroles of direct caregiver, educator, coordinator, consultant, administrator, and researcher has prepared OCNSs to assume responsibility as case managers in today's market. Given the limited interaction many health-care professionals have with patients in a successful managed-care environment, use of an OCNS to identify needs and mobilize resources can contribute greatly to the delivery of efficient care.
Some organizations have already recognized this and have converted OCNSs into case managers. However, in the process, the traditional role of the OCNS as staff educator may be sacrificed.
Need to Assume More Direct Patient Care Roles
Oncology APNs whose scope of practice includes medical diagnosis and performance of specific traditional medical procedures are increasingly in demand. The need to provide cost-effective care while maximizing appropriate use of physicians and enhancing the continuity of patient care, further contributes to the demand for this expertise.
With regard to meeting these physician-extender demands, there are areas in which the education of clinical nurse specialists has been insufficient. For example, historically curricula for a clinical nurse specialist have not included advanced pharmacology or training in the performance of medical procedures. The pharmacology requirement for clinical nurse specialists is currently being met in some states where titling gives them some level of prescriptive authority once course requirements are met.
Moreover, although the educational programs for many OCNSs include physical assessment courses, their traditional role did not require that they use these skills to take daily histories, perform physical examinations, or make medical diagnoses, as would be expected of an NP or a physician. However, these skills are necessary for APNs who wish to maintain a strong direct patient care role in todays market.
Oncology clinical nurse specialists can acquire the skills necessary for obtaining complete histories and performing physical examinations, but state-defined scope of practice may limit their ability to make medical, rather than solely nursing, diagnoses based on their assessments. They also may be less able to bill for their services than an NP would be, depending on the payor.
These limitations of OCNSs have prompted organizations to turn to NPs to fill direct patient-care roles. As McDermott Blackburn notes, some OCNSs are responding to this trend by enrolling in NP graduate or post-masters certificate programs to acquire the necessary additional knowledge and skills while maintaining their marketability.
Jacobs and Kreamer provide an overview of proposed models for advanced practice that variously conceptualize the relationship between OCNS and NP roles and how those roles can be merged into formal APN programs. They predict that a merger of OCNS and NP will occur by the year 2010, largely in response to market demands. These trends are further evidenced by the risefrom 2 to 23 between 1990 and 1996in oncology nurse practitioner and combined OCNS/NP programs.
Oncology Nursing Society (ONS) membership data from 1988 through 1997[Oncology Nursing Society National Office, personal communication, October, 1997] show a steadily increasing trend in the number of nurses reporting their primary role as NP or case manager. Although the number of clinical nurse specialists has progressively declined since 1994, it remains the most commonly identified role of the three. These data strongly support the previously discussed trends.
Case manager was a newly added response option in the 1996 member survey, reflecting the increased demand for this role within a managed-care environment. The dramatic increase from 95 to 498 case managers by 1997 further illustrates this. However, many of these individuals may not be APNs. Moreover, the data also likely reflect the movement of some APNs from the role title of clinical nurse specialist to that of case manager or NP, although this cannot be definitely determined.
Oncology Nurse Practitioners
Galassi and Wheeler identify four major related practice areas of oncology nurse practitioners: (1) cancer prevention and screening; (2) working collaboratively with oncologists to deliver care to patients undergoing active treatment; (3) caring for patients who have completed treatment and are being monitored for disease recurrence and long-term effects of treatment; and (4) caring for patients in the terminal phase of illness, especially symptom management. The role of the acute care nurse practitioner in oncology, as described by McDermott Blackburn, reflects a particularly increased practice focus in the second and fourth areas.
In a study by Kinney et al, oncology nurse practitioners reported their predominant patient population as adult outpatients, although many also had inpatient care responsibilities. These oncology nurse practitioners listed performance of a variety of procedures, including Pap smears, bone marrow biopsy, lumbar puncture, paracentesis, thoracentesis, proctosigmoidoscopy, skin biopsy, cyst/seroma aspiration, contraceptive device and peripherally inserted central catheter line insertions, colposcopy, laser therapy of the cervix, Ommaya reservoir injections/taps, and suturing. Their most frequently cited employment settings were university-affiliated hospitals (33%), comprehensive cancer centers (26%), and ambulatory-care centers (23%). They most often noted the differences between their role and that of a clinical nurse specialist as provision of more direct patient care, possession of more physical assessment skills, and use of a medical model in addition to a nursing model.
Merger of Oncology Clinical Nurse Specialist and Nurse Practitioner Roles
Acute care oncology nurse practitioners now enter a practice arena already attended to, in part, by their OCNS colleagues, who have traditionally worked in the acute care setting, although with a different role focus. This has focused greater attention on blending the roles of OCNS and NP. McDermott Blackburn briefly mentions the fact that there is much debate about the pros and cons of combining the roles.
Page and Arena warn against the pressure placed on a single individual who attempts to gain the knowledge and skills necessary to carry out both roles simultaneously. They worry about the loss of vital clinical nurse specialist functions, such as developing protocols and using evaluation tools to measure outcomes, if the blended role includes the assumption of more medical tasks. They question how advanced practice nursing will keep nursing, rather than medicine, as its primary focus, and whether the market should be the primary determinant of curricula and role functions.
The ONS Position Statement on Advanced Practice in Oncology Nursing states, The ONS endorses the title 'Advanced Practice Nurse (APN)' to designate CNS and NP roles in oncology nursing. The term Advanced Practice Nurse does not infer the merger of Clinical Nurse Specialist and Nurse Practitioner roles, nor does it exclude other masters-prepared nurses in education, administration, or research roles.
Hawkins and Holcombe support the title of APN, recognizing that the role of the APN varies, depending on the context in which the advanced practice occurs and the extent of blurring between practice areas. They point out that new examples of combined practice emerge almost daily, and rightly note that a singular title does not mean a singular function.
Advanced practice nurses perform many value-added functions, particular combinations of which are required to meet defined goals/needs within specific organizations. These are best met by individual APNs who possess the necessary knowledge, skills, education, certification, and experience to carry out those functions, regardless of their role title. McDermott Blackburn wisely states that managed care markets will not distinguish between these titles as long as the right care is being provided in the right place at the right price.
McDermott Blackburn emphasizes the need to combine the clinical expertise of all team members to create a stronger foundation for providing quality oncology care. This requires multidisciplinary planning within organizations to design efficient oncology care systems, utilizing the most appropriate providers to meet the needs of specific patient populations at various points in their care.
Oncology clinical nurse specialists and oncology nurse practitioners have significant skills to contribute to this process as planners, providers, and evaluators of care. Advanced practice nurses must work together, regardless of practice setting or role function, to not merely fill gaps vacated by others, but rather, to create and realize the vision necessary for the success of advanced practice nursing in an ever-changing health-care environment.