The Role of Advanced Practice Nurses in Oncology
Advanced practice nurses (APNs) play an essential role in the delivery of healthcare services across a wide spectrum of care needs. Patient safety, service quality and the effectiveness of care delivery all depend on the activity of healthcare practitioners, including APNs. In oncology, APNs play roles across several practice areas including collaboration with oncologists in care delivery for patients who are under active treatments; providing care for patients that have ended their treatments and are undergoing monitoring for the long-term drug effects and disease recurrence; and caring for terminally ill patients among others. In spite of the roles of APNs in oncology, various restrictions may exist to their practice in different states. For instance, the scope of practice for APNs in the State of California determines what APNs can or cannot do in relation to oncology practice. Similarly, the extent of involvement of APNs in oncology care varies from state to state depending on the scope of practice set by the different state Boards of Nursing (BONs).
Various studies have been conducted on the role of APNs in oncology care delivery as well as on other aspects of nursing practice and research. Most of the already conducted studies have not been linked to the scope of practice outlined by the State BONs, and are thus focused only on the capabilities of APNs in care delivery. This study explores the role of APNs in oncology with specific focus on the California practice laws for both nurse practitioners (NPs) and APNs. Existing studies and the practice laws for State of California will be used as the key resources for this study, and will be instrumental in developing the practice profiles for APNs and NPs in oncology care in California.
The transition of a nurse from a registered nurse (RN) to an APN is a process that results in the advancement of qualifications and expansion of clinical privileges that allow APNs to engage in more clinical activities than RNs. This expansion of roles creates an environment based on which APNs can support physicians in a wide range of clinical procedures and can also be counted on as nurse leaders in their respective places of practice. The roles of APNs in oncology can therefore be deduced to be an expansion of the roles of RNs practicing as NPs, with additional privileges subject to board and physician permissions.
The role of APNs in oncology begins from oncology research through to caring for terminally ill patients. They work with healthcare practitioners in research and development of new evidence-based approaches for the management of oncology cases. According to Welch, Ryan, and Galinsky (2017), successful oncological research requires the participation of a multidisciplinary team, in which APNs play a critical role. As part of the oncological research team, APNs play a vital role in the identification of the patients for inclusion in clinical trials, education of research participants, provision of supportive care to research participants, and development of effective environments for the research to progress seamlessly (Welch et al., 2017). The objective of clinical research in oncology is to develop new and effective treatments as well as supporting education on safety and efficacy on the present therapies and other novel combinations and the contributions of APNs make this feasible.
The place of APNs in oncology is attributed to their training and credentials in healthcare service delivery. APNs have more advanced training compared to other nurses participating in oncology care delivery. They can therefore be credentialed for the delivery of medical services that are reserved for physicians as well as those in which other nurses are involved. Schramp et al. (2010) posit that because of this credentialing, APNs can work collaboratively with physicians to perform more advanced physical assessments on oncology patients, to carry out various clinical procedures due to their clinical privileging, and to engage in diagnostic testing as required in study protocols for clinical trials. In both research and continuous clinical care for patients undergoing oncological procedures, the APNs can be considered important in the delivery of preventive care and supportive care in case of an adverse event. Thus, the presence of APNs during oncological research and practice is beneficial to the team engaged in research for the delivery of care in cases requiring immediate medical management and decision-making. Their presence can also help in developing a proactive preventive process that averts the probabilities of adverse events when working with patients (Schramp et al., 2010). The ability of APNs to be actively engaged to this extent is supported by their training and educational qualifications as well as by their work experiences. However, the use of this ability can be hindered by the restrictions posed in the scope of practice outlined by the state BON.
In addition to conventional research and clinical practice involvement by APNs, the qualifications associated with the APN status make it possible for APNs to engage in policy making. The APN is capable of identifying and being involved with all policy issues that face clinical practice and healthcare service delivery, including in oncology. Because of this capability, they should focus on issues that affect patients and their practice in general while also echoing messages of professional organizations aimed at improving healthcare service delivery (Kostas-Polston, Thanavaro, Arvidson, & Taub, 2015). Oncology practice is one of the areas of healthcare in which policy making is imperative due to the range of care practices and complications associated with it. The importance of policy in oncology practice implies that APNs have a significant role in oncology policy-making, and they are supported by various professional organizations. Organizations such as the AANP provide platforms through which APNs can share their policy perspectives and contribute to legislative issues affecting care delivery in clinical oncology.
The capabilities and qualifications of ANPs notwithstanding, there are restrictions to what they can do across the research, practice and policy-making regime. Specifically, the state regulations on practice provide directives that can be either restrictive or supportive of APN performance. In the State of California, the scope of practice of APNs is defined by the business and professions code for nurse practitioners. Part of the code states that NPs in the state can perform practices that meet the criteria that have been set out in the regulations including the standardized procedures. These criteria are developed in collaboration with health professionals and administrators including nurses, physicians and surgeons and are based on the professional codes of ethics (Board of Registered Nursing, 2013). The procedures permit nurses to engage in practices such as ordering durable medical equipment with prior approval from third-party payers; certifying disability upon conducting physical examination in collaboration with a surgeon or physician; approving, modifying or signing treatment or care plans for individuals under personal or home care services with physicians; and engaging in practice performance without any violations of the standardized procedures for care (California Board of Nursing, 2013). The Board of Registered Nurses further explains that NPs have to be clinically competent and to practice within their legal authority of practice pursuant to the Nursing Practice Act (NPA).
The NPA gives nurses the authority to perform roles that are essential in primary care delivery even without the need for standardized procedures including: conducting mental and physical health assessments, carrying out preventive and restorative measures on diseases, conducting immunizations and skin tests, withdrawal of blood samples for tests, and initiating emergency procedures (Board of Registered Nursing, 2011). Any activities beyond these are supposed to be based on consultations with physicians and other healthcare professionals as well as on the level of training and clinical competency of individual nurses. The APN therefore falls within the category of individuals with additional clinical competencies and whose scope of practice is expanded.
The roles of the APN in oncology are at the intersection of the capabilities and competencies of ANPs and the state BON’s scope of practice for APNs in clinical medicine. Unrestricted practice for APNs in any state has the potential to enhance care quality, improve efficiency in service delivery and enhance the cost-effectiveness of care (Hain & Fleck, 2014). Moreover, the qualifications and clinical experience of APNs mean that the collaboration between physicians, surgeons and other healthcare providers and the APNs can result in better outcomes for oncology patients. APNs should be allowed to practice across the entire scope of their training and education, but are frequently exposed to barriers within complex healthcare systems. Such barriers prevent APNs from being effective advocates for change in their different healthcare environments contrary to expectations. The barriers and challenges faced by APNs in effective delivery of care even to oncology patients can be linked to over-emphasis on the role of NPs in clinical systems and the insistence on collaborative over independent practice for APNs (Hain & Fleck, 2014). Identifying the state-level barriers to effective APN performance can help in increasing their contributions to oncology research and clinical practice.
One of the areas of oncology in which APNS have been shown to have critical roles is research. From the evidence provided by various authors, APNs play an important role in patient identification, education of research participants and provision of support to participants in research (Welch et al., 2017). All these roles are supported by the scope of practice for APNs in the state of California. The support to APN involvement in oncology research comes in the form of their freedom to be active participants in the clinical care environments through collaboration with physicians and other healthcare practitioners. Specifically, the scope of practice of NPs in general covers various roles including caring for a culturally and ethnically diverse population, working with underserved communities, and working across several healthcare settings, one of which is in oncology (Hain & Fleck, 2014). Through their constant contact with patients and continued interaction with them at a clinical and educational level, APNs have the opportunity to obtain first-hand information about patients, to know them, to be actively involved in their care and to possibly recruit them for participation in research. Since the state of California has no restrictions on the scope of practice of NPs within this spectrum of services as long as the practice is based on clinical competence and legal authority and is supported by healthcare professionals in other disciplines, APNs in the state of California can actively be involved in collaborative oncology research.
It is notable that APNs have also been recognized as leaders in healthcare service delivery. This implies that their clinical practice capacity is at par with the desirable levels across several states and healthcare needs. For oncology patients, APNs have the capacity to be involved in medical care practices such as diagnostic testing as well as delivery of preventive and supportive care (Schramp et al., 2010). These capabilities are tied to their trainings and clinical competence, and are also included in their legal authority of practice as outlined in the NPA. While the state of California does not specifically provide the scope of clinical practice for APNs different from that of the NPs, it recognizes the legal authority of the NPA, which has stipulations for the scope of practice for APNs. Specifically, the NPA states that beyond the conventional roles of NPs in a clinical setting, APNs should be recognized as nurse leaders and allowed the opportunity to explore their full potential while optimizing the use of the available physicians in oncology practice. Specifically, oncology APNs are involved in a wide array of practice activities including performing medical diagnoses and specific medical procedures. In this way, they provide cost-effective care by supporting the available physicians and enhancing care continuity to patients in demand of expertise (Reynolds & McCoy, 2016). With the existing scope of practice in the State of California, the support for physicians is inevitable, hence giving APNs the opportunity to serve more effectively in clinical oncology. For instance, NPs in the state are able to modify, approve and even monitor patients undergoing home treatment. This practice scope benefits oncology as most oncology patients are likely to undergo home treatment from time to time.
In terms of policy-making, the role of APNs in oncology is not yet clearly visible especially in the state of California. The potential for participation is there and the scope of practice does not specifically mention any restrictions to APN involvement in policy-making. The state provides an opportunity for the involvement of nurses, physicians and surgeons in consultative discourses through which the different levels of nursing practice are set based on the qualifications of nurses. The nurses have equal opportunities to participate in such consultations as the physicians and surgeons do (Board of Registered Nursing, 2013), and such opportunities imply that roles such as policy-making can be assigned to specific groups of nurses such as the APNs. Additionally, policy-making is in most cases steered by professional organizations such as the AAPN, and the State of California has not restricted any of the APNs from joining professional organizations. Through collaboration with other APNs in the professional body therefore, APNs in California can contribute effectively to policies that touch on oncology practice based on their clinical observations of patient needs and gaps in care delivery.
The role of APNs in oncology practice is undeniable as observed through the evidence provided. However, the most significant barrier to APN practice in any state is the restriction of practice. The State of California is part of the two-thirds of the country that is still practicing restrictive licensure of APNs, which means that APNs are unable to practice to the entire extent of their training and education. Restricted licensure in the State of California is such that the practice of APNs is regulated through the requirement that nurses should practice under supervision, delegation and collaboration with outside health disciplines such as physicians in order to be able to provide effective patient care (Hain & Fleck, 2014). The main rationale for advancements in training and licensure for APNs is to be able to provide sufficient support for physicians working in various aspects of healthcare service delivery, even to the point of reducing the need for physicians in certain areas (Reynolds & McCoy, 2016). Conventionally, oncology nurses reduce the pressure on physicians and enhance cost-effectiveness by contributing to the demand for expertise. This demand for expertise cannot however be filled in a context in which APNs are needed to partner with the physicians and cannot practice independently.
The role of APNs in oncology is quite extensive and covers three core areas namely oncology research, clinical oncology practice, and oncology policy-making and implementation. From the research conducted, APNs generally have the clinical competencies and the legal authority to engage in activities across all the three areas but may be restricted by state practice laws and regulations. In the State of California, it is deductible that APNs can engage in research as well as in clinical oncology practice and policy-making as long as there is collaboration with other healthcare practitioners, specifically physicians. This restriction indicates that the practice of APNs in California is dependent on the physicians, a requirement that prevents APNs from practicing across the entire scope of their training and education. Such restriction has been recognized as a major barrier to the practice of APNs across the healthcare spectrum.
Board of Registered Nursing (2011). General information: Nurse practitioner practice. State of California, Department of Consumer Affairs. https://www.rn.ca.gov/pdfs/regulations/npr-b-23.pdf
Board of Registered Nursing (2013). Business and professions code – Nurse practitioners: Laws and regulations. State of California, Department of Consumer Affairs. https://www.rn.ca.gov/pdfs/regulations/bp2834-r.pdf
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