Flexible Nurse Practitioners Solve Workforce Shortages

Pam Harrison

May 07, 2017

Making room for a multidisciplinary nurse practitioner (NP) in an oncology clinic can be a flexible, innovative solution to workforce shortages that frequently occur in these clinics, and that can impair the quality of patient care, new research shows.

"Every medical center has their own reasons for having provider shortages and staffing challenges: there's sick leave, medical leave, and other unforeseen circumstances," Michelle Lyn, AGPCNP, a multidisciplinary NP working at the Mount Sinai Medical Center in New York City, told Medscape Medical News. "But if someone like an attending physician is missing in an oncology practice for whatever reason, that leaves a huge dent in the service that the practice can provide, so being able to fill in that role seamlessly makes a huge difference."

Lyn presented her descriptive study on what a multidisciplinary NP does within a large oncology center at the Oncology Nursing Society (ONS) 2017 Annual Congress today in Denver, Colorado.

Essentially, a multidisciplinary NP performs the same tasks an oncologist does, with a few exceptions. For example, Lyn takes careful histories and performs thorough physical exams. She also reviews laboratory test and imaging results and creates and modifies chemotherapy plans. "You also discuss goals, side effects, provide teaching and counseling, plus symptom management, and make referrals to any specialty, as needed," Lyn added.

Of course, end-of-life discussions and care go hand-in-hand with oncology care, and at Mount Sinai, Lyn helps provide these services, together with the hospital's hospice and palliative care team.

"The key difference between what an oncologist does and what I do is that I cannot sign for chemotherapy — it always needs a cosignature from a medical oncologist," she said.

The trick to getting this role right seems to be flexibility, according to Lyn.

"Nurses are adaptable: We have to be, you have to fit into the team," she said. For example, some teams want the NP to see only follow-up patients; other teams want them to see only new patients so that they can gather all the relevant information about past medical history and discuss possible treatment plans before they move to other members of the team

"As a multidisciplinary NP, you also have to become familiar with each speciality practice, such as myeloproliferative neoplasm," Lyn noted. For example, it's important to measure the size of the spleen at every visit for patients with myeloproliferative neoplasms, as painful spleen enlargement can temporarily be treated with chemotherapy. And with that, NPs need to document findings to establish baseline dimensions and assess response to treatment.

"In neuro-oncology, it's also very important to do a thorough neurological exam, and that includes posture, motor and sensory activity, speech, reflex, cranial nerves, muscle tone, and memory testing, everything," Lyn explains.

"So we are able to tailor functions to each team we work with, and meet their specific goals and needs," she said.

These flexible, and highly skilled, individuals can thus basically fit in wherever there are staff shortages in an oncology unit and do just about anything. "Basically either week to week or day to day, nursing management will assign me to a specialty clinic, such as genitourinary oncology or thoracic oncology or multiple myeloma, and sometimes I can be stationed there for months, depending on what's going on," Lyn explained.

As an example of the seamless care she and other multidisciplinary NPs can deliver, Lyn told Medscape Medical News about work in the medical center's hematology/oncology clinic, which is one of their busiest clinics. In general, attending physicians in this clinic see between 24 and 28 patients a day, five to six of them new patients. "One of the attending physicians had to be out for almost a month, and while she was away, patients still need to get routine lab tests and maintenance treatment, and we were able to see all of her patients and provide quality continuative care during her absence," Lyn recalled.

Most important, patients were satisfied with the care they received during the attending physician's absence.

"The traditional medical model is for everyone to specialize in one field and become an expert in that field, and that's understandable, because you do one thing well and that builds efficiency," Lyn observed. "But there are going to be staff shortages in each of these specialty practices at one time or another, for whatever reason, and we need to address these shortages," she added. "So I think using a multidisciplinary NP is very do-able, and I think they [not only provide] a solution to solving shortages among oncology providers but [also] serve as a critical component for efficient and innovative oncology care systems," Lyn concludes.

Efficient, Financial Prudent Approach

Asked by Medical Medical News to comment on the role of the multidisciplinary NP in the healthcare system, Toby Bressler, PhD, RN, OCN, vice-president of oncology nursing and clinical quality at Mount Sinai Health System in New York City, points out that the prevalence of cancer in the United States is increasing. "By the year 2020, we'll have about 2.5 million people in the [United States] living with cancer, and if you look at the cost aspect of it, the National Cancer Institute talks about how $125 billion was spent in cancer care delivery in 2010, and that is only projected to increase," Dr Bressler said.

"So we need to start thinking of unique ways in which we plan and deliver care in the most financially prudent, but also the most clinically competent, way possible, and using an advanced practice nurse is the perfect complement."

This was part of the impetus for the Mount Sinai Medical Center to create an innovative way for them to meet the needs of the volume and the complexity of care of an oncology patient, Dr Bressler notes. "By using this type of novel staffing pattern, we have found it to be a win-win for the providers and for the patients," she observed. "And this particular provider, Michelle, happens to have all the clinical expertise in the various disease groups and she's looking at the patient holistically in terms of providing the best nursing and medical treatment possible," Dr Bressler adds.

"So it's a very nice partnership between the physician oncologist and the advanced practice nurse."

Lyn and Dr Bressler have disclosed no relevant financial relationships.

Oncology Nursing Society (ONS) 2017 Annual Congress: Abstract 19. Presented May 6, 2017.

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