The once identifiable hallmarks of the American entrepreneurial
health-care systemaccess to care on demand, unrestricted
provider choice, and a relatively stable delivery systemhave
been supplanted by a process of health-care management commonly
referred to as managed care. In the broadest sense, managed care can
be defined as a variety of methods to finance and organize the
delivery of comprehensive health care with attempts made to control
costs by limiting the provision of services. This description of
managed care characterizes the integration of financing,
cost-containment strategies, and business principles with the
delivery of health care. Or, as medical sociologist David Mechanic
stated, managed care is moving health care from advocacy to allocation.
A Pew Health Professions Commission Report predicts that 80% to 90%
of insured Americans will move under the umbrella of managed-care
systems over the next decade. Recent statistics support these
predictions. In 1996, Medicare enrollment into managed-care plans
grew by 27% and Medicaid enrollment grew by 33%. The number of new
health maintenance organization (HMO) enrollees doubled over the past
8 years to 64 million, with nearly three-quarters of American workers
receiving their coverage from a variety of managed-care plans; also,
63 new HMOs were licensed, bringing the total number to 630.[4,5] The
unpredictable managed-care market has been described by economists as
a buyers market, producing not only underused hospitals
but specialists who are forced to compete for the diminishing number
of fee-for-service patients.
Intrinsic to specialty practice is the routine use of costly
diagnostic tests and the need to acquire state-of-the-art technology
so as to remain competitive. There is also a general sentiment that
specialists are more expensive. Compared to the
practice patterns of primary-care physicians, managed-care
organizations (MCOs) view specialty practices as resource-intensive
and specialists as cost centers. This has led to the
implementation of strict gatekeeping practices,
systematic utilization management reviews, and the implementation of
practice guidelines by MCOs to decrease specialty referrals.
The oncology community has voiced its objections to these documented
managed-care practices (eg, restricted access to specialty care,
administrative challenges to professional autonomy and clinical
decision-making, and reduced employment opportunities for specialists
within MCOs.) In response to these market changes, some
physicians have formed their own health provider groups and
integrated health systems. Friedman defines an integrated delivery
system as having a core of physicians on salary or exclusive
contract, with a common culture and a consistent product. The system
is run by a single board, and offers a full array of health care
services provided through capitation for a defined set of populations.
Adapting to the managed-care market has also challenged another group
of oncology care providers, advanced practice nurses (APNs), who are
being markedly affected by the cost-containment and reengineering
efforts hospitals are employing in attempts to remain competitive. In
1995, Milliman and Robertson speculated that in an optimally managed
system, only 0.8 beds per 1,000 (assuming 85% occupancy) will be
required as hospital occupancy levels continue to decline. This
number suggests that about three out of every four hospital beds
currently in use will not be needed to meet the inpatient needs of
the US population.
Recently released statistics by the American Hospital Association
show that, between 1991 and 1995, approximately 190 facilities
stopped providing inpatient acute-care services and 335 community and
noncommunity facilities closed. The unprecedented wave of
hospital closures and the systematic increase in hospital/corporate
mergers will cause the loss of 200,000 to 300,000 nursing positions.
Furthermore, other industry statistics indicate that there are about
2.6 physicians (1.0 primary-care practitioners and 1.6 specialists)
for every 1,000 people in the United States. In optimally managed
systems, only 0.5 primary-care physicians and 0.8 specialists are
really needed per 1,000 patients. These system changes have
mobilized the nursing profession to assess and reexamine advanced
practice nursing and, on an individual basis, are prompting APNs to
remain marketable by acquiring new skills, additional administrative
and professional degrees, such as mbas and jds, and advanced certifications.
Building on the preceding information, this paper will now identify
who APNs are, how diverse APN roles are being implemented in oncology
practice settings, the market influences affecting APN/physician
relationships, and emerging roles and opportunities for APNs within oncology.
Nursing can trace the term specialist back to the turn of
the century, when postgraduate courses were offered by hospitals. The
first issue of the American Journal of Nursing, published in 1900,
included an article entitled specialists in Nursing that
addressed the development of specialized clinical practice. By 1980,
the American Nurses Association affirmed that Specialization is
a mark of the advancement of the nursing profession.
Nevertheless, it is important to distinguish between specialization
in nursing and advanced nursing practice. Specialization
involves concentration in a selected clinical area within the field
of nursing. Advancement, as described by Cronenwett,
involves both specialization and expansion. Expansion refers to the
acquisition of new practice, knowledge and skills, including
the knowledge and skills that legitimize role autonomy within areas
of practice that overlap the traditional boundaries of medical
practice. The term expanded role has been used throughout
the nurse practitioner literature.
Within the nursing community, there is no clear definition of
advanced nursing practice. Calkin has proposed a conceptual
definition, and other authors have defined advanced nursing
practice in terms of particular roles. To offset this lack of
consensus, specialty organizations, such as the Oncology Nursing
Society (ONS), have developed a core definition of advanced practice
for their specialties. In 1990, the ONS defined advanced nursing
practice as expert competency and leadership in the provision
of care to individuals with actual or potential diagnosis of cancer.
Advanced practice nurses generally function as licensed registered
nurses who have met advanced educational and practice requirements
and are prepared at the graduate level. The defining characteristics
of advanced nursing practice, as described by Hamric et al, include
three primary criteria and eight core competencies. The three primary
criteria are graduate education, certification, and a practice
focused on patient and family. The eight core competencies include
clinical practice expertise, expert guidance and coaching,
consultation, research skills, clinical professional leadership,
collaboration, change agent skills, and ethical decision-making
skills. These competencies encompass all roles and cross all
Of the 2.2 million registered nurses in the United States, about
100,000 are APNs. There are four established advanced practice
roles: nurse practitioners (NPs), nurse anesthetists (CRNAs), nurse
midwives (CNMs), and clinical nurse specialists (CNSs). There are
also many abbreviations used in state legislatures to describe APNs
(see box on page 00). Of these four groups, approximately 25,000 are
nurse practitioners; 40,000 are clinical nurse specialists; 5,000 are
certified nurse midwives; and 20,000 are certified registered nurse anesthetists.
On a state-by-state basis, many legal and regulatory inconsistencies
exist both between and within APN roles. Variations also exist among
states regarding titles, scope of practice, collaborative protocols,
practice agreements, and prescriptive authority. Advanced nursing
practice varies among institutions and practice settings, but there
are marketable leadership skills common to all APN roles. These
include mastering change, systems thinking, shared vision, continuous
quality improvement, redefining health care, and service to the
community. These leadership qualities are incorporated into the
oncology roles of the CNS and NP. The focus of this paper will be a
discussion of these established functions and the emergence of case
managers, acute care nurse practitioners (ACNPs), and blended CNS/NP roles.
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