Commentary: New Findings Substantiate the Successful Use of Nurse Practitioners and Physician Assistants in Collaborative Practice Models

On behalf of the Oncology Nursing Society (ONS), I'd like to first thank Susan G. Komen for the Cure for funding this very important and timely study of nonphysician practitioners (NPPs), which includes both nurse practitioners (NPs) and physician assistants (PAs). With more than 3,000 advanced practice nurse members, including NPs and clinical nurse specialists, ONS has a specific interest in the results of this study.

ASCO projects that by the year 2020, there will be a shortage of medical and gynecologic oncologists, resulting in a deficit of 2,550 to 4,080 physicians caring for people with cancer. People are living longer, and, as Towle and Barr¹ point out, by 2020 the number of people living with or surviving cancer will increase by 81%. In addition, the Patient Protection and Affordable Care Act will provide health care access to approximately 42 million more adults and 8 million more children in the United States. Although not all of these newly insured people will present with or develop cancer, the number of patients requiring cancer care will undoubtedly increase as a result of improved access. Given that our health care system will experience a shortage of oncologists, who will care for all of these patients either living with or surviving cancer?

As I noted in a recent edition of ASCO Post, “In my estimation, there is room for excellent cancer care provided by numerous health care providers including physicians, nurse practitioners, and physician assistants.”^2(p2) Yet, historically, NPPs have not been used to their potential in caring for people with cancer. Towle and Barr¹ noted three reasons why NPPs have not been used in the past.

• Physicians were not interested in working with NPPs.

• There was not enough patient volume to use NPPs.

• When physicians have worked with NPPs in the past, they felt that they “just didn't work out.”

Given the impending shortage of physicians coupled with the increased likelihood of more patients with cancer in the very near future, perhaps the results of the Towle and Barr study¹ may help to change some minds. The importance and benefit of working together for better outcomes for patients with cancer and their families will be of critical importance in the future.

Towle and Barr¹ found that more than 98% of patients were aware that an NPP was providing clinical services to them, and that more than 92% of patients were extremely satisfied with the care they received from an NPP. These important results lend support to Towle and Barr's statement, “… we believe there should be no lingering concerns that patients will react negatively to oncology care provided by nonphysician practitioners in a collaborative practice model.”

Recall that one of the reasons that practices from this study didn't use NPPs was because when they had done so in the past, the NPPs “didn't work out.” Ironically, results from the same study seem to contradict that finding. Practices in which NPPs worked with all physicians and saw a wide variety of patients demonstrated a 19% increase in overall productivity. Although some variability existed, the overall satisfaction of physicians working with NPPs in the study group was 7.98 out of 10, or 79.8%. Similarly, the overall NPP satisfaction score was 7.82, or 78.2%. These findings suggest that NPPs are productive and helpful to the practice, and that both physicians and NPPs are satisfied with a collaborative practice. With an increase in patients with cancer, using NPPs effectively could lessen physicians' workloads, improve patient outcomes, and result in positive professional experiences for oncology care providers.

This study challenges us to make sure that we have a qualified workforce to care for patients with cancer. It is not yet clear whether there will even be enough NPPs, specifically oncology NPs, to assist with the impending oncologist shortage. Another challenge is the shortage of nursing school faculty, who are imperative to the development of new NPs. NPs will need to develop and maintain expertise and competence in providing care to patients with cancer.

As the professional home for oncology nursing, ONS has many programs and resources developed to prepare oncology-specialized and nononcology NPs. For example, in past years, ONS has held the Nuts and Bolts of Advanced Oncology Care workshop preceding its annual Advanced Practice Nursing Conference. This one-day workshop was designed to teach nononcology NPs about the basics of cancer care. ONS is working with ASCO to hold a similar program before the ASCO 2011 Breast Cancer Symposium. Essentials of Oncology: A Workshop for Nurse Practitioners will give those with little or no oncology background the foundation needed to care for their patients with cancer. ONS offers many publications and Web courses for NPs. In 2007, ONS created and published Oncology Nurse Practitioner Competencies (http://ons.org/media/ons/docs/publications/npcompentencies.pdf), which can be used to educate nononcology NPs about the specialty.

Another way that NPs can demonstrate their expertise and knowledge in the care of patients with cancer is through certification. The Oncology Nursing Certification Corporation (www.ONCC.org) offers certification examinations for both the oncology NP (Advanced Oncology Certified Nurse Practitioner; AOCNP) and the oncology clinical nurse specialist (Advanced Oncology Clinical Nurse Specialist; AOCNS). In fact, more than 1,000 nurses have obtained certification in oncology nursing as AOCNPs and AOCNSs.

One important limitation of this study is that both NPs and PAs are lumped into the single category of NPPs. Considering that some physicians have not wanted to work with NPPs in the past, it could be helpful to see whether their concerns were specific to NPs, PAs, or both. This identification would then allow organizations such as ONS to help address any barriers to full utilization of NPs practicing in oncology.

The results from this study provide strong evidence in support of using NPPs in collaborative practice. These results should put to rest the old notion that patients are less satisfied when cared for by an NP or PA. Now is the time to proactively focus on these and other solutions to the potential increase in patients with cancer and the predicted shortage of oncologists. By supporting positive professional experiences, we can reach our collective goal of providing access to high-quality cancer care for all.

Author's Disclosures of Potential Conflicts of Interest

Although all authors completed the disclosure declaration, the following author indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a “U” are those for which no compensation was received; those relationships marked with a “C” were compensated. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors.

Employment or Leadership Position: Carlton G. Brown, Oncology Nursing Society (U) Consultant or Advisory Role: None Stock Ownership: None Honoraria: None Research Funding: None Expert Testimony: None Other Remuneration: None