The article by McDermott Blackburn describes advanced practice in oncology nursing in the managed-care environment. The strength of this article is its detailed description of the traditional roles of the clinical nurse specialist and the nurse practitioner. The author identifies the controversial trend to merge these two distinct advanced practice roles in oncology nursing, and highlights another significant trend—the evolving role of case management in comprehensive cancer care.
Although McDermott Blackburn acknowledges these important milestones in oncology nursing, this section of the article lacks the same contextual depth given to defining the traditional advanced practice roles. Indeed, the author offers a more spirited discussion of the impact of managed care on physicians and nurses than the more crucial and timely issue of advanced practice in oncology nursing during the managed-care era.
Impact of Managed Care
McDermott Blackburn accurately captures the legacy of managed care’s impact on acute-care facilities: closures, fewer services offered, and hospital/corporate mergers. The author describes the impact on nursing in general as a loss of registered nurse positions and the “downsizing” of oncology clinical nurse specialist services, resulting in “delegating inappropriate tasks to assistant personnel, which compromises the oncology patient’s condition and care outcomes.” This quotation is not attributed or referenced, and it would be interesting to know whether it reflects the author’s personal experiences.
My own experiences as an oncology staff nurse in a large western city’s private community hospital during a merger with a larger, national for-profit corporation were somewhat different. Although no staff nurse positions were lost, many nurse management and ancillary support staff positions were “right-sized,” redesigned, or eliminated. More chemotherapy treatments were scheduled on an outpatient basis or were performed in physicians’ offices.
My patient caseload nearly doubled to dangerously unsafe numbers, my new name tag did not identify me as a registered nurse, and much of my time was spent performing nonnursing tasks and delegating direct patient care. By rationing myself, I am sure that I had a negative impact on patient satisfaction. My daily prayer was to avoid compromising anything more than that.
Within that institution, there were no advanced practice roles for a nurse with a master’s degree that could be downsized or eliminated. Perhaps because consumers and administrators are unable to identify advanced practice nursing as a major contributor to quality nursing care, the advanced practice nursing role will remain invisible in the acute-care setting.
Advanced Practice Nurse as Case Manager
McDermott Blackburn carefully compares and contrasts the traditional roles of the clinical nurse specialist and the nurse practitioner, and quotes the 1990 Oncology Nursing Society’s advanced practice nursing definition. The author briefly describes the controversy surrounding the merger of these roles. Oddly enough, she omits the Oncology Nursing Society’s position statement on advanced practice, which represents a significant milestone in oncology nursing.
McDermott Blackburn describes “value-added” components of the advanced practice nursing role as identified by “administrators, nurse leaders, and physicians.” Although the author does not identify who these people are, or where or how they practice, this “wish list” of attributes of the advanced practice nurse includes case management skills. Case management is another important trend in advanced practice nursing.
McDermott Blackburn beautifully illustrates the assumption of the role of case manager as a key trend in advanced practice in oncology nursing. She aptly describes the additional skills each traditional role would need to acquire in order to become a successful case manager in today’s managed-care environment. Situated in a small western city in which only 7% of the citizens are enrolled in a managed-care delivery system, my institution is avidly studying case management models for the anticipated 25% increase in managed care.
I suspect that adopting a case management role would change my practice just as significantly as earning an advanced practice degree did. By clearly defining and articulating the outcomes of my own practice to my managers and hospital administrators, I hope to create and develop my future role as an advanced practice nurse in oncology into a more powerful position rather than a precarious one.
The advanced practice nurse in oncology is in a perfect position to assume many of the functions of a case manager in today’s rapidly changing health-care systems. These include:
Managing and coordinating care for the clinically complex and resource-intensive population of people with cancer and their families;
Providing health education, teaching self-care behaviors, and offering the psychosocial counseling and support that is so crucial to the quality of life of people with cancer and their families;
Assessing the efficacy of the health-care delivery system along the continuum of care; and
Facilitating and monitoring improvement initiatives of the health-care delivery system.
While I cannot alter the chaos of a rapidly changing health-care delivery system, I can certainly choose my responses. I can courageously “gird up my loins” like King David, polish my leadership and collaborative practice skills, creatively strategize my opportunities, and continue my commitment to personal and professional growth. I do not think that I will be lacking for challenging opportunities in the future as an oncology advanced practice nurse.
1. Hamric AB: Creating our future: Challenges and opportunities for the clinical nurse specialist. Oncol Nurs Forum 19(1; suppl):11-15, 1992.
2. Oncology Nursing Society: Oncology Nursing Society position statement on advanced practice in oncology nursing. Oncol Nurs Forum 22(8; suppl):45, 1995.
3. Shuren AW: The blended role of the clinical nurse specialist and the nurse practitioner, in Hamric AB, Spross JA, Hanson CM (eds): Advanced Nursing Practice: An Integrative Approach, pp 375-394. Philadelphia, WB Saunders, 1996.
4. Hawkins R: Concluding remarks: Window to the future of advanced practice in oncology nursing. Oncol Nurs Forum 22(8; suppl):43, 1995.
5. Mahn VA, Spross JA: Nurse case management as an advanced practice role, in Hamric AB, Spross JA, Hanson CM (eds): Advanced Nursing Practice: An Integrative Approach, pp 445-465. Philadelphia, WB Saunders, 1996.