Background: Oncology nurse practitioners (ONPs) are advanced practice RNs prepared at the graduate level with high-level knowledge and skills in oncology. Because of challenges in educational programs and variability in the scope of practice at the state and institutional level, many ONPs are challenged to practice to the full extent of their education, certification, and licensure.
Objectives: The purpose of this article is to review issues affecting the education and practice patterns of ONPs and to identify solutions to address the challenges that exist for ONPs.
Methods: Members of the Oncology Nursing Society’s Nurse Practitioner Summit summarized the challenges faced by ONPs related to education, training, practice, and professional development.
Findings: Efforts to promote ONP practice at the fullest extent of licensure and across various settings should be prioritized. Resources must be devoted to education, onboarding, and retention to integrate and retain ONPs as leaders of the interprofessional team.
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Oncology nurse practitioners (ONPs) are advanced practice RNs (APRNs) prepared at the graduate level with high-level knowledge and skills within the specialty of oncology. This preparation enables ONPs to provide expert care for patients across the cancer care continuum. Based on state regulatory requirements, ONPs deliver a comprehensive range of healthcare services, such as compiling health histories, performing physical examinations, ordering and interpreting diagnostic studies, diagnosing and treating acute and chronic medical conditions, managing symptoms related to cancer treatments, and prescribing pharmacologic and nonpharmacologic therapies (i.e., chemotherapy, narcotics, counseling, education, and patient support) (American Association of Nurse Practitioners [AANP], 2018a; Brant & Wickham, 2013). ONPs actively collaborate with other members of the interprofessional team to ensure the delivery of quality care for patients with cancer and their caregivers.
The scope of practice for ONPs is regulated by the nursing practice acts defined by the laws and regulations of each individual state. In some states, ONPs have full practice authority, which allows them to practice independently without supervision by physicians, whereas in other states, ONPs have limited practice authority. To date, 22 states and the District of Columbia allow full, autonomous practice for ONPs (AANP, 2018b) (see Figure 1). Legislative efforts are ongoing across the nation with the intent to increase the number of states allowing full ONP practice authority.
Oncology Nurse Practitioner Training and Education
The Institute of Medicine ([IOM], 2011) report, The Future of Nursing: Leading Change, Advancing Health outlined the role of nurses in a complex healthcare delivery system. Four essential messages were identified: (a) Nurses should practice to the full extent of their education and training; (b) nurses should achieve higher levels of education and training through an improved educational system that promotes academic progression; (c) nurses should be full partners with physicians and other healthcare professionals in redesigning healthcare in the United States; and (d) effective workforce planning and policymaking require better data collection and information infrastructure.
This report recognizes the importance of nursing in achieving the goals of the Affordable Care Act (ACA), including expanding access, shifting care delivery from treatment to prevention, improving healthcare quality and safety, providing culturally competent healthcare to vulnerable populations, reducing costs, and improving healthcare efficiency and delivery by using healthcare information technology (U.S. Department of Health and Human Services [USDHHS], 2018).
As APRNs, nurse practitioners (NPs) are healthcare providers who are well poised to meet these goals, with a growing number of NPs annually entering practice. According to data provided by the AANP, the number of certified NPs has significantly increased since the ACA was passed into law, with more than 248,000 currently certified NPs (AANP, n.d., 2018a) (see Table 1); however, the number practicing in oncology in the United States is unknown (Coombs, Hunt, & Cataldo, 2016) because no centralized licensing or registration pathway exists for ONP practice.
As the landscape of healthcare changes, there is an increased need for NPs to obtain further education and emerge as healthcare leaders. NP students have options related to which degree to pursue, including a Master of Science in Nursing or a Doctor of Nursing Practice (DNP). NPs must have the ability to disseminate research and clinical information to improve health outcomes, leading to a better understanding of healthcare management (American Association of Colleges of Nursing [AACN], 2015; National Organization of Nurse Practitioner Faculties [NONPF], 2016). For these reasons, it is recommended that all NPs obtain a DNP as the entry-level educational preparation for practice (AACN, 2015; NONPF, 2016).
Several challenges face the nursing profession in providing education for nurses pursuing advanced degrees. These include the difficulty in meeting educational needs for the number of people seeking advanced nursing degrees, a national nursing faculty shortage, and a lack of available clinical placement sites and preceptors. These educational problems have the potential to create an unstable environment for future NPs (AACN, 2015; Fitzgerald, Kantrowitz-Gordon, Katz, & Hirsch, 2012).
As of 2017, the United States had 373 NP academic programs (Fang, Li, Stauffer, & Trautman, 2016) that educate NPs to care for at least one age-specific population. Subspecialty programs, such as oncology, are uncommon in graduate NP programs, and the majority of ONPs do not attend a program with a formal oncology concentration. A survey conducted by the Oncology Nursing Society (ONS) reported that only 16% of NPs had completed a program with a primary focus in oncology (Nevidjon et al., 2010). To that point, most NPs achieve oncology expertise by means of on-the-job training by physician or NP colleagues, or by independent study (Hollis & McMenamin, 2014).
Traditional ONP orientation typically involves an assigned preceptor who observes and mentors the clinical practice of the NP, with or without prepared classroom instruction, most commonly over a three- to six-month period. This is insufficient for the NP new to the oncology setting. Additional education is needed to enhance the skills and knowledge required to provide care to the patient with cancer and his or her family members/caregivers (Nevidjon et al., 2010; Rosenzweig et al., 2012). Therefore, incorporating ongoing oncology education for months following the ONP orientation is necessary for individual healthcare facilities. During an orientation period, the goal for the ONP is to provide safe, quality care to patients in a supportive practice environment. In an environment of healthcare complexity, ONPs benefit from a comprehensive orientation that is the foundation of professional job satisfaction and retention (Barnes, 2015).
In a study by Rosenzweig et al. (2012), 164 ONPs responded to a survey about their knowledge and skills as they entered oncology practice. Seventy-eight percent reported that they were not at all or just somewhat prepared for clinical issues, particularly chemotherapy and biotherapy competencies. It was also reported that 61% were not at all prepared or only somewhat prepared to recognize and manage medication toxicities. In addition, 70% reported being somewhat prepared or not at all prepared to care for patients with oncologic emergencies. The results of this study are indicative of significant changes in preparation and mentoring as ONPs begin practice in an oncology setting.
Technology and online programs are effective teaching methods to bridge the gap when training new ONPs. The ONP Web Education Resource (Onc-PoWER) was developed with funding from the National Cancer Institute (NCI) for NPs new to the oncology setting (Hoffmann, Klein, & Rosenzweig, 2017). Simulation is another teaching method that is particularly useful when learning to perform clinical procedures (AACN, 2017; Fitzgerald et al., 2012; Merchant, 2012; National Council of State Boards of Nursing [NCSBN], 2014).
Equally as important in the process of educating newly hired ONPs is identifying and supporting ONP preceptors specialized in the field of oncology (Bazzell, Jones, Dains, & Champion, 2017). In addition to developing clinical skills and knowledge, new ONPs also require mentoring in the areas of professional collegiality and confidence building when communicating with patients and colleagues. These objectives are best achieved by NP preceptors rather than physician colleagues (Rosenzweig et al., 2012). For an effective preceptor to best educate and mentor a newly hired ONP, the preceptor needs training and support.
Educating and training a successful ONP workforce is a collaborative effort that involves academic institutions, healthcare facilities, professional organizations, and individual ONPs. Learning is a lifelong process that is essential to provide effective care to patients with cancer. The overall goal is to prepare ONPs to practice as independent providers in a collaborative clinical setting that provides safe, quality, and compassionate care to people with cancer (Fitzgerald et al., 2012; LeFlore & Thomas, 2016).
Congruent with the IOM’s (2011) Future of Nursing report, there is movement at the state level to seek alignment and uniformity in licensure for all APRN roles: NPs, nurse midwives, nurse anesthetists, and clinical nurse specialists (CNSs) across six population foci through the APRN consensus model (NCSBN, 2008) (see Figure 2). Endorsed by ONS and the Oncology Nursing Certification Corporation (ONCC), this model was developed through work by the NCSBN APRN Advisory Committee and the APRN Consensus Work Group. It is aimed at assisting healthcare providers, state and national legislative bodies, and the general public to better understand the role of the APRN and provide uniformity in regulation (NCSBN, 2008).
Although the target date to reach consensus was December 2016, fewer than half of the states in the United States have achieved full practice authority (NCSBN, 2018). The model has had a major effect on creating uniformity in educational preparation and entry to practice, which will make it easier and more accessible for APRNs to practice and move from state to state.
NPs who hold national certification must maintain population focus–specific requirements for practice and renewal. As more state practice acts adopt and comply with the APRN consensus model, existing NPs who were trained outside those population-specific foci (i.e., trained as an adult NP versus an adult/gerontological NP) may find that they are grandfathered into practice with their prior education and certification, but will likely be required to maintain existing licensure and certifications to be compliant, based on the requirements of their state (NCSBN, 2010). Existing NPs practicing in specialty areas will also most likely be required to maintain those population-specific requirements in addition to their specialty requirements. ONPs must remain aware of evolving issues related to practice and regulatory and reimbursement activities that affect practice in their states.
Another issue affecting licensure is continuing education (CE). Maintenance of certification, CE credits, and practice portfolios may assist ONPs in documenting continuing competence. With evolving technology, maintaining records of such activities for purposes of licensure, certification, and credentialing may become less cumbersome for practitioners.
ONPs possess highly specialized knowledge and skills to function optimally in their roles across the disease spectrum. In addition to certification in both the role of the NP and specific population foci, ONPs are encouraged to seek specialty certification to validate their knowledge in the oncology specialty. Oncology nursing certification through ONCC provides validation of the specialized knowledge and experience required for competent performance and meets rigorous national standards that are reliable and legally defensible measurements of oncology nursing knowledge (ONS, 2017). The role of ONPs continues to evolve with microcredentialing and badging emerging as innovative ways to ensure specialty-specific knowledge.
Credentialing and Privileging
Credentialing is the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services (Joint Commission, n.d.). Documentation of credentials includes verification of licensure, education, certification(s), and clinical experience to function in a role. In addition, clinical privileging is a process by which organization(s) authorize NPs to perform a specific scope of services based on the evaluation of skills and competence to perform said skills. NPs may apply for privileges within their scope of practice defined by their state practice act. Privileges, such as writing orders for chemotherapy and performing oncology-related procedures, such as bone marrow biopsy, may require direct or indirect supervision by the physician, pending scope of practice at the state and institutional levels. In addition to the period of focused professional practice (observation of competent performance), privileges require ongoing evaluation of competence (Holley, 2016).
ONPs may practice in a variety of inpatient and outpatient oncology settings. Clearly delineated privileges are necessary to define the practice parameters of the NP and should encompass all potential practice settings for those ONPs who practice across sites within an organization. Beyond validating qualifications and evaluating competency of the NP, credentialing and privileging help to promote the provision of safe care for the patient (Kleinpell, Hravnak, Hinch, & Llewellyn, 2008).
Professional Growth and Development
The importance of lifelong learning continues as treatment options and technology evolve. ONS conducted a member survey of NPs in 2017, with 491 respondents. The survey revealed changing practice needs and challenges related to professional practice. Results showed that CE was obtained by attending conferences, reading journals and online activities, participating in tumor boards/grand rounds, and enrolling in academic courses (ONS, 2017). Respondents recommended including more NP-focused content in ONS journals, specifically offerings that include pharmacology content, and at conferences.
Each state regulates and mandates the number and timing of CE requirements for its NPs. Most, but not all, require NPs to complete a minimum number of CE hours. Many certifications also require a minimum number of contact hours, with some requiring specific contact hours in defined practice populations and topics, such as pharmacology or individual learning needs assessment (ILNA) subject areas (American Academy of Nurse Practitioners [AANP] Certification Board, 2018; American Nurses Credentialing Center [ANCC], 2016; ONCC, 2018).
ONS provides CE specifically for NPs through a variety of means discussed in more depth later in this article. The Advanced Practitioner Society for Hematology and Oncology offers education through regional lectures, national conferences, and its journal (Journal of the Advanced Practitioner in Oncology). The American Society of Clinical Oncology (ASCO) offers courses through the ASCO University Advanced Practitioner Certificate Program. This program offers CE credits through a series of three oncology programs, covering topics related to symptom management, treatment, and supportive care: Oncology Basics 101, Oncology Basics 102, and Advanced 201.
Certain barriers hinder ONPs from staying current with CE. These include work/life demands, cost, and access. In addition, provider schedules can vary and be hectic, limiting time for ONPs to access CE. Some CE is free, whereas others are accessible for a fee that may be reimbursable by employers. Time and cost may limit travel to conferences for CE, with many institutions reducing the amount of financial support provided for educational activities.
ONS has been a supportive source for the practice and professional development of APRNs, including ONPs.
• The Standards of Oncology Nursing Education: Generalist and Advanced Practice Levels was published in 1989, and the Standards of Advanced Practice in Oncology Nursing was published in 1990.
• A special interest group for ONPs began in 1990 and is now presented online as the NP community.
• ONP competencies were first published in 2004, then revised with the second edition released in 2007 (ONS, 2007). These are being updated as part of a larger project to update the Standards and Scope of Practice for APRNs to reflect current specialty practice in oncology.
• A role delineation study (RDS) to determine the key knowledge and skills ONPs possess was conducted by ONCC in 1993 and informed the first advanced oncology certified nurse (AOCN®) certification in 1995. An RDS for oncology APRNs was repeated in 2005, with the determination made to split the AOCN® certification into two areas: one for the advanced oncology certified nurse practitioner (AOCNP®) and another for the advanced oncology certified clinical nurse specialist (AOCNS®). A repeat RDS for the AOCNP® examination occurred in May 2018.
• ONS publishes multiple resources for ONPs (see Figure 3), including two books specifically tailored for their practice: the Clinical Manual for Oncology Advanced Practice Nurse and the Advanced Oncology Nursing Certification Review and Resource Manual.
• The Clinical Journal of Oncology Nursing (CJON) and the Oncology Nursing Forum publish articles with content relevant to ONP practice. CJON and the ONS Voice have columns dedicated to advanced practice in each issue.
• ONS offers five courses that are specifically created for ONPs and that can be taken individually or bundled together in preparation for the AOCNP® examination. These include topics related to prevention and diagnosis, professional practice, quality of life, symptom management, and treatment. ONS also offers two courses designed to provide ONPs, CNSs, and physician assistants with limited or no oncology experience with core knowledge needed to care for patients with cancer and hematologic disorders: Post-Master’s Foundation in Cancer Care and Post-Master’s Foundation in Hematology.
• A dedicated advanced practice track at ONS Congress features sessions with higher-level education on treatments and treatment-related side effects, genetics and genomics, ONP-run clinics, and opioids in cancer care. In 2018, a pre-Congress workshop was added specifically for clinical skills for ONPs. Knowing that not all ONPs can attend Congress, ONS began live streaming and archiving the APRN-dedicated sessions in 2017 to allow ONPs to watch remotely at their convenience.
• In addition, all ONS Congress sessions are coded for ILNA points so certified APRNs can get CE needed to maintain AOCNP® certification.
In December 2017, the ONS NP Summit was held to further explore the issues confronted by ONPs. At the summit, 13 ONS NP members and 8 ONS staff members (see Figure 4) met to determine the needs of ONS members who practice as NPs in cancer care settings, assess the current ONS resources, and plan for the development of resources, partnerships, and products to meet the clinical needs of ONPs in cancer care settings. Recommendations by the participants will direct the development of resources and policies to address the identified needs of ONPs.
ONPs are key to improving the quality of care for patients with cancer through advocacy, both within their institutions and in legislative offices at the state and national levels. ONS’s Center for Advocacy and Health Policy held a policy summit (Policy Barriers and Opportunities to NPs in Oncology) in April 2018, in Washington, DC. The summit brought together more than 50 healthcare experts, ONPs, advocates, industry leaders, and patient groups. Sessions featured speakers from federal agencies, including the Centers for Medicare and Medicaid Services as well as AANP and NCI. The panels discussed topics such as the variability in NP scope of practice by state and institution, the contributions of NPs to primary and oncology care, concerns about reimbursement for services, and the disparate availability of cancer care in rural and underserved populations that affects cancer outcomes. The findings from the policy summit reinforced the need to educate the public and policymakers about the role and contributions of NPs to affordable, accessible, and quality cancer care.
As the need for cancer care in the United States continues to grow with advances in treatment options, aging of the population, changing workforce demographics, and new cancer care delivery models, ONPs will be integral to the delivery of high-quality care. Efforts to promote their practice at the fullest extent of the license and across various cancer care settings are imperative. Resources should be devoted to ONP education, onboarding, and retention to ensure that they not only are able to effectively integrate themselves into the healthcare system, but also establish themselves as leaders of the interprofessional team. ONS has led efforts to support and promote ONP practice and remains committed to the growth of the profession.
About the Author(s)
Heather Mackey, MSN, RN, ANP-BC, AOCN®, is a nurse practitioner (NP) of cancer prevention and wellness and a manager of cancer support services at the Derrick L. Davis Forsyth Regional Cancer Center in Winston-Salem, NC; Kimberly Noonan, DNP, RN, ANP-BC, AOCN®, is an NP at the Dana-Farber Cancer Institute in Boston, MA; Lisa Kennedy Sheldon, PhD, APRN, AOCNP®, FAAN, is the chief clinical officer at the Oncology Nursing Society in Pittsburgh, PA; Marybeth Singer, MS, ANP-BC, AOCN®, ACHPN®, is an NP at Tufts Medical Center in Boston; and Tamika Turner, DNP, NP-C, AOCNP®, is the director of cancer survivorship at Community Health Network in Indianapolis, IN. The authors take full responsibility for this content. Mackey is an independent contractor for the Oncology Nursing Society and a director-at-large for the ONS Board of Directors, and has received additional support from the ONS Foundation and Elseiver. Sheldon has received support from the American Cancer Society. Singer previously served as the Oncology Nursing Certification Corporation board president. Turner has previously consulted for MJH Associates and has served on speakers bureaus for the Aplastic Anemia and MDS International Foundation. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias . Mackey can be reached at firstname.lastname@example.org, with copy to CJONEditor@ons.org. (Submitted May 2018. Accepted July 9, 2018.)
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