by Wai Man Ling, Hong Kong East Cluster, Hong Kong, China. ISNCC Communications Committee Member.
A 51-year-old leukaemia patient died of post chemotherapy septicaemia after a 5-hour delay in antibiotics treatment in Hong Kong 4 years ago. The incident has drawn the attention in the public and the healthcare community again after the verdict of Coroner’s Court in November 2015 (Lo, 2015). The coroner attributed the tragedy to a series of unfortunate mistakes, especially the multiple delays in the antibiotics treatment when the patient attended the two Accident and Emergency Departments (AEDs) for fever. She continued to urge the Hospital Authority (HA) of Hong Kong to review the existing clinical practice. Emergency protocol should be in place and there should be adequate instructions to the patients and the family members prior to post chemotherapy discharge (Lau, 2015).
Neutropenic fever is a known oncological emergency. Its mortality can be largely reduced by prompt and appropriate responses from the attending healthcare professionals. I believe that this unfortunate but real case can once again illustrate the risk vividly and further boost our vigilance. In response to the incident, the HA is now co-ordinating a number of remedial actions in the local public hospitals. Management guidelines will be developed. Emergency antibiotics kit is being considered to install in all the Accident and Emergency, Oncology, and Haematology Departments to facilitate a timely initiation of antibiotics treatment.
Moreover, concerns from the external accreditation body have given extra momentum to the move. Just take my hospital as an example, the external surveyors scrutinized the policies and performance of my Department in this area during their visit last year. Thereafter, we had implemented a number of improvement measures. We conducted a retrospective baseline audit on the door-to-needle (DTN) time for antibiotics treatment for the period of 2013-14. Similar to the findings of other local audits, our performance fell short of the international recommendations in terms of the mean DTN time (Chan, Wong, & Wu, 2015). Then, we developed the new clinical management guidelines, and collaborated with our AED and Pharmacy to establish a new workflow. Currently, we are conducting a post audit to review the effectiveness of our new practice.
On the other hand, our experience has underlined some pivotal roles played by the oncology nurses in enhancing the service. Firstly, we help to design the emergency protocol and the Chemotherapy Alert Card, and incorporate this new information in the pre-chemotherapy education for patients. Secondly, we liaise with the various Departments to establish an agreed workflow. We have then briefed the staff members on this workflow, and also educated the doctors and nurses of our AED on the use of different types of central catheters for blood culture and antibiotics treatment. Thirdly, we help to collect patient data for the post clinical audit.
Through this sharing, I would like to restate the importance of the prompt management of post chemotherapy neutropenic fever, and the significant contributions that oncology nurses can make in this area.
The new Chemotherapy Alert Card for the patients in our Department
Chan, S. H. O., Wong, K. M. I., & Wu, Y. G. P. (2015). Clinical Audit on Initial Management of Neutropenic Fever Patients. Unpublished manuscript, Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong.
Lau, C. (2015, November 19). ‘A series of unfortunate events’: Hong Kong coroner rules cab driver whose hospital treatment was delayed died of natural cause. South China Morning Post. Retrieved from http://www.scmp.com/news/hong-kong/law-crime/article/1880148/series-unfortunate-events-hong-kong-coroner-rules-cab
Lo, K. (2015, November 19). Natural causes ruling after leukemia delays. The Standard. Retrieved from http://www.thestandard.com.hk/news_print.asp?art_id=163364&sid=45601959
by Cynthia Abarado, University of Texas M.D. Anderson Cancer Center, Houston, United States. ISNCC Communications Committee Member.
The advanced practice registered nurse (APRN) role is increasingly being adopted in a global context, yet the roles, responsibilities, and requirements, including education, licensure, and certification, of APRNs are as diverse as the settings within which they practice (Pulcini, 2010). This article presents an overview of APRN roles and practice globally and in the United States, as well as the integration of APRNs at one National Cancer Institute-designated comprehensive cancer center in the southwest United States.
Advanced Practice Nursing- A Global Perspective
First developed largely as a role to meet a growing need for primary care provision, particularly in areas in which there was a dearth of physicians, advanced practice nursing has grown to encompass a diversity of roles and specializations. Though advanced practice is commonly associated with the nurse practitioner role, is it an umbrella term that encompasses several academically prepared roles. These include the nurse practitioner, the clinical nurse specialist, the nurse anesthetist, and the certified nurse midwife (Table 1). Though these individuals are largely prepared at the Master’s level, there is tremendous diversity in how these individuals are prepared at the international level, ranging from baccalaureate through doctoral level content. APRNs are employed in diverse practice settings, including primary care, acute care, specialty clinics or hospitals, as well as in community based organizations. The clinical responsibilities of APRNs are largely dictated by national, local, and institutional rules and regulations governing practice. The range of responsibilities is broad, including supervised practice, in which APRNs work under the direction of a medical doctor, to complete autonomy in practice, in which APRNs are independently able to prescribe and oversee health clinics. A descriptive study conducted in 2008 provided insight into the diversity of roles, titles, practice settings and responsibilities of APRNs from an international perspective (Pulcini, Jelic, Gul, & Loke, 2010).
Advanced Practice Nursing in the United States
There are over 267,000 APRNs in the United States (National Council of State Boards of Nursing [NCSBN], 2015a). The APRN Consensus Model has provided a generalist structure to nursing education and credentialing, with the four roles presented in Table 1 constituting the accepted generalist APRN roles recognized in the United States. Academic preparation has historically been at the Master’s level, however the Doctor of Nursing Practice has recently been recommended and is being adopted as the entry to practice degree. Further specialization (e.g. women’s health, oncology) is elective and dependent upon the individual’s interest in pursuing additional education, training and practice hours that allow for specialty certification. Such certification is granted by specialty organizations such as the Oncology Nursing Society. Licensure occurs at the state level and is dictated by the individuals state’s Boards of Nursing. This scope of practice for APRNs differs by state and by role within each state, including eligibility for prescriptive authority and levels of autonomy in practice. Practice is defined as independent, in which no requirement for a written collaborative agreement, supervision, or conditions for practice; or not independent, which either a written agreement specifying scope of practice, direct supervision by a licensed physician (NCSBN, 2015b). Once licensed at the state level, APRN competencies are determined and verified by the individual institutions within which APRNs are employed.
Oncology Advanced Practice Nursing
APRNs are an integral component to an interprofessional team providing care to patients across the cancer continuum, from screening (Zapka, 2003), through diagnosis, treatment, survivorship (Corcoran, Dunne & McCabe, 2015) and end-of-life care. The Oncology Nursing Society (2015) states that the role of the APRN in oncology practice is to “provide leadership to improve outcomes for patients with cancer and their families by increasing healthcare access, promoting clinical excellence, improving patients’ quality of life, documenting patient outcomes , and increasing the cost-effectiveness of care.” APRNs also have a significant role in promoting cancer prevention across practice settings, conducting cancer risk assessment, and exploring genetic links to cancer occurrence with patients (Abarado, Brassil, Brydges, & Dains, 2014). When integrated as part of a diverse interprofessional team APRNs have the potential to have significant impact on patient care, particularly in the oncology setting (Blakely & Cope, 2015; Gosselin, Dalton, & Penne, 2015).
APRN Practice in a National Cancer Institute-designated Comprehensive Cancer Center
At a National Cancer Institute-designated comprehensive cancer center in the southwestern United States employs over 400 APRNs in either advanced practice nurse (APN) or certified registered nurse anesthetist (CRNA) roles. The CRNAs work predominantly in the operating room to assist with anesthesia administration and monitoring during surgical procedures. The APNs consist of both nurse practitioners and clinical nurse specialists who have delegated prescriptive authority and provide direct clinical care to oncology patients. APNs work in both the inpatient and ambulatory settings and provide care from point of entry to the institution through survivorship and end of life care. Their roles and responsibilities are as a diverse as the populations and areas in which they serve.
APNs work as members of an interprofessional team in the inpatient setting. The team is led by a physician specialist, and may consist of one or more APNs, a doctorally prepared pharmacist, and medical trainees (e.g. residents or fellows). The daily patient census, patient acuity, and complexity involved in individual patient care determine the daily work flow and processes. The day may begin with a meeting before the interprofessional team rounds on patients to conduct a multidisciplinary review of all patients, identification of priority, emergent and urgent cases and development of interventions and plan of care with an inpatient attending physician. APNs’ clinical practice involves concurrent and dynamic processes requiring effective communication skills, interprofessional collaboration, leadership and most importantly a strong knowledge base of disease and disease management in oncology. Quality care outcomes focus on safe, timely, effective, efficient, and patient-centered care. APNs have an important role in integrating evidence-based practice and developing practice guidelines to guide safe and effective care for patients. APNs engage with an electronic health record for the documentation of patient care and outcomes. The proficient use of digital communications and technologies play inherent roles in today’s health care delivery. Responsibilities of an inpatient APN are highlighted in Figure 1.
In the ambulatory setting APNs work both at this institutions main campus, as well as in our community-based settings to provide coordinated care for patients across the cancer continuum. APNs may serve as the primary provider in the ambulatory setting to assess and manage patient care in between physician visits. This includes evaluating diagnostic findings to initiate therapeutic interventions including infusions and transfusions, and to facilitate symptom management related to disease and treatment complications. Ambulatory APNs are also primarily responsible for facilitating survivorship clinics within the disease-site or treatment specific centers (e.g. Breast, Stem Cell Transplant, Head & Neck).
Regardless of practice setting the APRN role is dynamic and involves balancing diverse responsibilities inherent in holistic nursing care. APRNs serve as clinicians, performing assessment of and developing plans of care for patients; researchers, participating in the development, implementation and evaluation of research protocols to enhance clinical care and professional practice; quality improvement professionals, initiating evidence-based quality improvement initiatives and guidelines to promote safe and effective clinical care and professional practice; educators, developing, implementing, evaluating and sharing education both within and external to the institution; case managers, facilitating transition between diverse care settings; navigators; coordinating care and supporting safe and effective transitions across the cancer continuum; patient advocates, acting as liaisons between patients and members of the interprofessional team both within and outside the hospital to ensure that patient defined goals of care are achieved; leaders, serving as leaders within this institution either formally in supervisory roles, or through participation in institutional committees and task forces, as well as in community organizations.
As the APRN role continues to grow and expand both nationally and globally there are many opportunities to continue to grow and develop the APRN profession and the roles defined within it. Continued collaboration among APRNs in diverse roles and practice settings across countries may contribute to a richer sense of identity and opportunity for the profession to continue to evolve and advance. While this article focuses on the integration of APRNs in one practice setting in the United States it highlights both the similarities and the differences in the manner in which these roles and responsibilities are experienced both within the United States and in the global community.
Kelly Brassil, PhD, RN
Joyce Dains PhD, JD, APRN
Jacqueline Broadway-Duren DNP, APRN
Mary Cline, MSN, APRN
APRNs with Clinical Nurses
Department of GU Medical Oncology APRN Group
Abarado, C., Brassil, K., Brydges, G., & Dains, J. (2014). Health policy implications for advanced practice registered nurses related to oncology care. In K.A. Goudreau & M. Smolenski (Eds.) Health Policy and Advanced Practice Nursing: Impact and Implications (pp. 235-250). New York, NY: Springer Publishing.
Blakely, K. & Cope, D.G. (2015). Establishing an advanced practice nursing clinic in the cancer setting. Seminars in Oncology Nursing, 31(4), 282-289. doi: 10.1016/j.soncn.2015.08.004.
Corcoran, S., Dunne, M., & McCabe, M.S. (2015). The role of the advanced practice nurse in cancer survivorship care. Seminars in Oncology Nursing, 31(4), 338-347. doi: 10.1016/j.soncn.2015.08.009.
Gosselin, T.K., Dalton, K.A., & Penne, K. (2015). The role of the advanced practice nurse in the academic setting. Seminars in Oncology Nursing, 31(4), 290-297. doi: 10.1016/j.soncn.2015.08.005.
National Council of State Boards of Nursing. (2015a). NSCBN’s APRN Campaign for Consensus: State Progress Toward Uniformity. Retrieved November 11th, 2015 from https://www.ncsbn.org/5397.htm
National Council of State Boards of Nursing. (2015b). About the APRN Consensus Model. Retrieved November 11th, 2015 from https://www.ncsbn.org/736.htm
National Council of State Boards of Nursing. (2008). The Consensus Model for APRN regulation, licensure, accreditation, certification, and education. Retrieved November 11th, 2015 from https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf
Oncology Nursing Society. (2015). The Role Of The Advanced Practice Nurse In Oncology Care. Retrieved on 11/12/2015 from https://www.ons.org/advocacy-policy/positions/education/apn
Pulcini, J., Jelic, M., Gul, R., & Loke, A.Y. (2010). An international survey on advanced practice nursing education, practice, and regulation. Journal of Nursing Scholarship, 42(1), 31-39. doi:10.1111/j.1547-5069.2009.01322.x.
Zapka, J.G., Taplin, S.H., Solberg L., & Manos, M.M. (2003.) A framework for improving the quality of cancer care: the case of breast and cervical cancer screening. Cancer Epidemiology, Biomarkers & Prevention,12(1),4-13.