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 supply-and-demand issue: There was a clear lack of physician 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?
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):
- 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 across the United States. These are a well-trained group who perform reimbursable services. Advanced practitioners obtain medical histories, diagnose, and prescribe. They perform procedures such as bone marrow biopsies and lumbar punctures.8 Although many advanced practitioners function independently, it is common to work with a collaborative physician.
Advanced practitioners play a key role in the diagnosis and management of patients with hematologic disorders. Research shows that patient satisfaction, patient safety, and quality indicators support the use of these providers across settings – especially in hematology/oncology. Different certifications exist but one thing is clear: Changes to the health-care system and a physician shortage solidify the role of these individuals, who have become integral to practice.
- Semmelweis I. (1983). The etiology, concept, and prophylaxis of childbed fever. Madison, WI: The University of Wisconsin Press.
- Best M, Neuhauser D. Ignaz Semmelweis and the birth of infection control. Qual Safe Health Care. 2004;13:233-4.
- Rosenberg C. (1995). The care of strangers: The rise of America's hospital system. Baltimore, MD: Johns Hopkins University Press.
- Mariotto AB, Robin Yabroff K, Shao Y, et al. Projections of the cost of cancer care in the United States: 2010–2020. J Natl Cancer Inst. 2011;103:117-28.
- Oliver GM, Pennington L, Revelle S, Rantz M. Impact of nurse practitioners on health outcomes of Medicare and Medicaid patients. Nurs Outlook. 2014 Aug 1. [Epub ahead of print]
- CMS-1607-F and CMS-1607-CN. Federal register. 2014;79:49853-50536.
- Zhang SQ, Polite BN. Achieving a deeper understanding of the implemented provisions of the Affordable Care Act. Am Soc Clin Oncol Educ Book. 2014:e472-7.
- Towle EL, Barr TR, Hanley A, et al. Results of the ASCO Study of Collaborative Practice Arrangements. J Oncol Pract. 2011;7:278-82.
- Donald F, Kilpatrick K, Reid K, et al. A systematic review of the cost-effectiveness of nurse practitioners and clinical nurse specialists: what is the quality of the evidence? Nurs Res Pract. 2014;2014:896587.
- National Organization of Nurse Practitioner Faculties. Independent practice and the Certified Nurse Practitioner: A white paper from the National Organization Of Nurse Practitioner Faculties. 2013.
- Institute of Medicine (2010). A summary of the February 2010 forum on the future of nursing: Education. Washington DC: The National Academies Press.
- National Commission on Certification of Physician Assistants. (2014). 2013 Statistical profile of Certified Physician Assistants. Accessed from www.nccpa.net/Upload/PDFs/2013StatisticalProfileofCertifiedPhysicianAssistants-AnAnnual- ReportoftheNCCPA.pdf.
|Title and Certifications||Credentials/Certifying Organization||How Were They Trained?||What Do They Do?|
|Certified Nurse Practitioner (CNP)Advanced Practice Registered Nurse (APRN)Advanced Practice Nurse (APN)Nurse Practitioner (NP)||American Nurses Credentialing CenterAmerican Academy of Nurse Practitioners (AANP)||Master's degree (usually at least 2 – 3 years) with certification, or "grandfathered" in by certification, to allow authority to practice and prescribe||A CNP is a licensed APRN who has completed a prescribed educational program that includes advanced knowledge, skills, and abilities in assessment, diagnosis, treatment, and management. Most CNPs can prescribe and maintain independent practices. Eighteen states allow APRNs "full practice authority" to diagnose and treat without physician involvement.*|
|Clinical Nurse Specialist (CNS)Adult Health Clinical Nurse Specialist (AHCNS)||American Nurses Credentialing Center (ACNS-BC)||Master's degree with certification to allow the authority to practice and prescribe||Similar to a CNP, but a CNS's education focuses on a defined field of study (such as perinatal nursing, infectious disease nursing, education, or cardiovascular nursing). CNSs are trained to become clinical experts in their field and base their practice on research and theory. Many states allow certified nurses to diagnose and prescribe.|
|Physician Assistant (PA)||National Commission on Certification of Physician Assistants (PA-C)Master of Physician Assistant Studies (MPAS)||Master's degree or by certification||PAs are similar to CNPs, but they trained in the medical model rather than nursing domain. There has been a distribution shift (females > males) and 62% of all female PAs are under 40 years of age; 37.6% of all male PAs are under 40 years.12|
|Doctor of Nursing ScienceNursing DoctorateDoctor of Science in Nursing||DNScNDDSN||Focused in clinical practice (rather than research, as with PhD)||These degrees are replaced by newer DNPs, and curricula have been revised to provide consistent education and ability to practice as NP. Not all DNScs, NDs, or DSNs can practice as NP or CNS without additional certification.|
|Doctor of Nursing Practice||DNP||Doctorate focused in clinical practice (rather than research, as with PhD) with certification to allow the authority to practice and prescribe||DNPs function similarly to NPs, but they have an advanced research education.|
|Doctor of Philosophy in Nursing or PA Science||PhD||Doctorate focused on research/scholarship||Not all PhDs will practice as NPs or PAs unless a certification has been obtained through an accredited body (usually ANCC, NCCPA)|
|Licensed Independent Practitioner (LIP) or Certified Healthcare Practitioner (CHP)||MD, DO, NP, CNS, PA, DDS, OD, CNM, CRNA||Any physician, dentist, nurse practitioner, and nurse midwife or any other||An LIP is an individual permitted by law and the organization to provide care and services without direction or supervision, within the scope of the individual's license and consistent with individually granted clinical privileges.|
|Mid-level Practitioner (MLP)||CNP, CNS, PA, CNM, CRNA||Pursuant to Title 21, Code of Federal Regulations, Section 1300.01(b28)||MLP refers to an individual practitioner – other than a physician, dentist, veterinarian, or podiatrist – who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in which he/she practices to dispense a controlled substance in the course of professional practice.**|
|Source: Clarification of Credentialing & Privileging Policy Outlined in Policy Information Notice 2001-16 (effective 2002-2022).Accessed from:http://bphc.hrsa.gov/policiesregulations/policies/pdfs/pin200222.pdf|
|*Full practice states without physician involvement: AL, AZ, CO, DC, HI, ID, IA, ME, MT, NH, NM, ND, NV, OR, RI, VT, WA, WY**Mid-level practitioners per state. Accessed from: www.deadiversion.usdoj.gov/drugreg/practioners/mlp_by_state.pdf|
- 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, physician 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.