New line in your job description: Nurse Practitioner Educator

June 24, 2010

The NP working in your practice may have knowledge gaps of which you are unaware. At the moment, you're responsible for solving the problem.

Of course you chose very carefully when you added a nurse practitioner (NP) to the practice. Like others in your situation, you're generally quite happy with your decision. But unless your NP has specialist training in oncology, you may be unaware of considerable gaps in his or her expertise.

Unfortunately, for the time being, it's up to you to discover and define these gaps, and then to fill in the missing information.

Oncology practices are turning increasingly to NPs for patient services, and many NPs want to provide cancer care. But most NPs working in oncology practice have graduated from programs that didn't specialize in oncology, according to a recent report in the Journal of Oncology Practice, and few NP training programs in the US even offer such a specialty. Most NPs new to oncology practice feel themselves "not at all" or "only somewhat" prepared to deal with clinical issues relating to chemotherapy or biotherapy (78%) or to recognize and manage oncologic emergencies (71%) or drug toxicities (61%)-although they feel very skilled in general care competencies such as history-taking and physical exams.

This information comes from an online survey of NPs conducted last summer and published in the Journal of Clinical Oncology among the abstracts for the recent ASCO annual meeting. The 30-item electronic survey was crafted by a team of oncology NPs led by Margaret Rosenzweig, PhD, who is herself and oncology NP an assistant professor in the University of Pittsburgh School of Nursing Department of Acute and Tertiary care. They sent the survey to 610 people in the Oncology Nursing Society (ONS) database who identified themselves as oncology nursing practitioners.

Far and away the most common information source for those NPs new to oncology who felt largely unqualified to offer specialist cancer care was the supervising physician in the oncology practice. While management of oncologic emergencies can be taught on the job, clearly it's a tall order to expect a supervising physician to keep staff up to date on all matters of therapy. As oncology (like so many other areas of medicine) is relying on NPs to fill a personnel shortage, what's needed is a new training curriculum for NPs--and pronto. But it doesn't exist yet.

Complicating the issue is the fact that local standards for NP training and licensure vary widely across the United States, as well as the AMA's opposition to independent medical practice for NPs as stated in a Scope of Practice document published last fall. The AMA's efforts "are divisive and impede rather than enhance patient access to quality care," Rosenzweig and others wrote in the Journal of Oncology Practice last January.

A few formal efforts have been undertaken to fill the NP knowledge gap in oncology. The ONS offers training workshops in oncology, but on-the-job training is "an absolute necessity," and "for now the training has to occur locally to a great degree," says Edward Balaban, a medical oncologist who practices at the University of Pittsburgh Cancer Center (and uses an NP).

A lack of uniformity in the existing ONS curriculum for oncology nurse practitioners has been a topic of some discussion between ASCO and the ONS, adds Balaban, who has been very involved with ASCO on matters of guideline implementation and clinical services.

Why can't there be, in this year of 2010, a simple online course to which you could refer your new NP to bring him or her up to speed on the basics of oncology? This isn't just wishful thinking; Rosenzweig has begun to develop one, in close collaboration with ONS. She believes that specialty nurses should create the curricula for specialist NPs, but that the mentor should be involved in finding clinical examples relevant to the practice environment in which the student works. Rosenzweig is seeking funding to complete the electronic curriculum and disseminate it nationally.

Meanwhile, Balaban observes, no two practices are alike, and each one needs to renew its "fund of knowledge" regularly and to define for itself how an NP will function within the team. Reviewing and enhancing an oncology NP's state of knowledge is bound to be a considerable commitment for both the physician mentor and the NP.

"This takes time initially," Balaban adds, "but the potential payoff once the substrate knowledge is in place is well worth the effort."