UP FRONT
APP Perspectives
In this column, we will hear from an increasingly represented and crucial
component of hematology/oncology care: advanced practice professionals/
advanced practitioners. In the first edition, ASH Clinical News Associate
Editor Beth Faiman, PhDc, MSN, APN-BC, AOC, starts by asking a basic, but
complicated, question:
What Should You Call Us?
Nurse practitioners, clinical nurse specialists, nurse anesthetists, nurse midwives, and physician’s assistants (PAs)
are like most hematologic cancers and blood disorders:
heterogeneous in presentation. These skilled clinicians
have advanced degrees and certifications and share similar job functions, yet each has a different scope of practice
and level of independence.
Most function within a collaborative team under
the auspices of a physician or hospital system regulated
by state legislation. Some states, however, allow fully
independent practices that do not require that physicians
partake in a practitioner’s decision-making process.
Historically, terms such as mid-level practitioner,
licensed independent provider, non-physician provider,
and physician extender have been used to combine
nursing and physician’s assistant groups. To complicate matters, some of these advanced practitioners
have master’s degrees and doctorates (so, should their
title be “doctor nurse” or “doctor PA”?). While some
of these name designations have a legal basis, others
might be interpreted as being derogatory, and fail to
capture the essence of the advanced practitioner who
specializes in hematology/oncology.
The history of this diverse group of clinicians helps
illustrate what is known about the roles of the Advanced
Practice Registered Nurse (APRN; a distinction which
encompasses nurse practitioners, clinical nurse specialists,
certified nurse midwives, and certified registered nurse
anesthetists who use the medical model to practice nursing) and PAs (educated in the medicine domain; SIDEBAR).
Where Did We Come From?
As hospitals were once intended to house the insane and
quarantine the contagious homes and places of worship became the first “hospitals” as we might recognize
them today. Wives, mothers, and religious communities
assumed the role of caregiver to “nurse” the sick back to
a state of health – or to deliver babies. Midwives were
among the first advanced practitioners to meet the needs
of women in labor and provide evidence for quality care.
In 1847, an obstetrician by the name of Ignaz Semmelweis observed that doctors and medical students had
a higher rate of post-delivery mortality (“childbed fever”)
than midwives, in large part due to excellent handwashing techniques on behalf of the midwives.1,2 In some
ways, midwives can be credited with some of the earliest
known infection control practices.2
Later, following World War II and the Korean conflict,
enlisted men assumed the role of medics during combat. In the field, these highly skilled soldiers performed
surgeries and provided lifesaving care; returning home,
though, they were jobless.
Quite coincidentally, advances in medicine and
injuries of post-war veterans led to a health-care supplyand-demand issue: There was a clear lack of physician
22
ASH Clinical News
providers. Thus, the NP and PA roles were born to fill a
gap in physician shortages during the 1960s.3
We are in the midst of another medical personnel
shortage, in part due to recent changes to the U.S. healthcare system. As a result, these roles are expected to grow
in importance over the next 10 years.4-7
No matter what you call “us,” it is clear that advanced
practitioners (in my opinion, the distinction one should
use when grouping APRNs and PAs together) provide efficient, cost-effective, and high-quality care to patients.8-10
APRNs and PAs in the United States are more than
267,000 and 87,000 members strong, respectively, and are
employed in a variety of practice settings. In contrast to
our colleagues
in medicine,
though, we lack
a consistent, professional practice
model.5,9,10
Nearly 1
percent of all
APRNs and PAs
are in the fields
of hematology
and oncology.
With so many
advanced practitioners, how can
this group best
be used? Where do they fit within an institution’s practice
model?
ADVANCED
PRACTITIONERS
PLAY A KEY
ROLE IN THE
DIAGNOSIS AND
MANAGEMENT OF
PATIENTS WITH
HEMATOLOGIC
DISORDERS.
What Exactly Do We Do?
The Institute of Medicine and other agencies have recognized the importance of producing highly trained nurses
and PAs. Through a two-step process, advanced practitioners are able to practice at the highest scope, commensurate with their education and training (TABLE, page 24):
• First, the individual attends one of many licensed
schools of nursing or PA science to confer a master’s
or doctorate degree.
• Second, the individual becomes certified in his/her
specialty area from a variety of organizations.11
While the variety of credentials can lead to confusion
among colleagues and patients, the basic requirements are
similar: Each clinician must complete a minimum number
of clinical hours (which vary from state to state) and pass
a rigorous certification examination. Yearly continuing
education is required to maintain the certification.
In recent years, there has been a push toward consistent practice models among advanced practitioners
Continued on page 24
Fast Facts
about Advanced
Practitioners
• The roles of APRNs and
PAs were born out of
a need for individuals
to access high-quality
health care. Access to
high-quality care in
hematology/oncology
will ALWAYS be
important.
• APRNs and PAs are
highly trained, but
various certifications
are available which
can confuse colleagues
and the consumer. A
push in the last decade
has led to greater role
clarity.
• Terms such as midlevel, ph ysician
extender, and nonphysician provider
can be viewed as
derogatory. Call us a
title commensurate
with certification – NP,
CNS, or PA.
• When in doubt, call us
“advanced practitioners
in hematology/
oncology.” This
professional distinction
can encompass the
educational preparation
among groups and
instill confidence in
patients and caregivers.
December 2014