NON-PHYSICIAN PRACTITIONERS IN RADIATION ONCOLOGY: ADVANCED PRACTICE NURSES AND PHYSICIAN ASSISTANTS

Systems for delivering health care in the United States have undergone significant restructuring in recent years. In the field of radiation oncology, with changes in reimbursement and a decrease in the number of residents, there is a need to explore new ways of achieving high quality patient care in both academic and private practice settings. One mechanism for achieving this is the implementation of non-physician practitioner roles, such as the advanced practice nurse (APN) and physician assistant (PA). To address this issue, in the spring of 1997, the American Society for Therapeutic Radiology and Oncology (ASTRO) established the Joint Committee on Advanced Practice Nursing Roles comprised of radiation oncology physicians, residents, and nurses working in both academic and private practice settings. One goal of the committee was to provide educational information regarding implementation of APN and PA roles in radiation oncology. Specific issues addressed included: definition of roles, regulation, prescriptive authority, reimbursement, considerations in implementation of the role, educational needs related to the unique clinical and technical aspects of radiation oncology, and impact on the training of residents. The committee is not advocating for or recommending that radiation oncologists incorporate APNs or PAs into their clinical practice. This is a decision that must be made based on the needs of the practice and the alternative resources available to meet these needs. There is much uncertainty about what the future holds in relation to health care, and there are more questions than there are answers about how to plan for that future. The intent of this paper is to raise awareness and provide information to assist physicians and nurses in making decisions about: (1) whether or not APNs or PAs are appropriate for their practice, (2) which type of provider would be most effective, and (3) how best to implement this role. Corresponding author: Joanne Frankel Kelvin, RN, MSN, AOCN, Ambulatory Care, Memorial Sloan-Kettering Cancer Center, New York, NY. telephone: ; fax: ; e-mail: Accepted for publication 28 April 1999. Int. J. Radiation Oncology Biol. Phys., Vol. 45, No. 2, pp. 255–263, 1999 Copyright © 1999 Elsevier Science Inc. Printed in the USA. All rights reserved /99/$–see front matter 255 TYPES OF NON-PHYSICIAN PRACTITIONERS Non-physician practitioners include advanced practice nurses (APNs) and physician assistants (PAs). These practitioners have a number of characteristics in common, particularly the focus on direct patient care. However, it is important to understand the differences between these roles to ensure that the appropriate provider is selected to provide the services needed by the practice or department. Advanced practice nurse (APN) The APN is a registered nurse with advanced academic education and clinical expertise in a health care specialty. Roles include the clinical nurse specialist (CNS) and nurse practitioner (NP). The Clinical Nurse Specialist (CNS) role emerged in the 1950s to improve the quality of care by enabling expert nurses to stay at the bedside. Clinical Nurse Specialists practice primarily in the acute care setting, although they are also found in ambulatory and home care settings. The CNS is an expert clinician, and direct patient care is a major responsibility of the CNS in most settings. However, the CNS role also includes education, clinical leadership, consultation, and research. This may involve such specific activities as: education of staff, patient and family education, facilitation of groups to enhance collaboration, development of new clinical programs, policy analysis, coordination of research protocols, administration, and supervision and mentoring of staff. The focus is often on the system of health care delivery, working as a change agent to ensure attainment of organizational goals and quality patient care. The Nurse Practitioner (NP) role emerged in the 1960s to increase patient access to primary health care. The NP is trained in the medical model as a direct provider of care, and the role blends aspects of medicine and nursing. Nurse Practitioners practice primarily in the ambulatory care setting, although they are increasingly found in acute care roles in the in-patient setting. The NP is qualified to diagnose and manage acute and chronic illness, either independently or collaboratively with physicians. This may involve such specific activities as: obtaining medical histories and conducting physical examinations; ordering and interpreting laboratory, radiological, and other routine diagnostic tests; prescribing medical interventions, treatments, and medications; and counseling and educating patients and families. The NP is licensed to diagnose, treat and prescribe independently; however, NPs in the oncology setting generally practice collaboratively with physicians. The Physician assistant (PA) The PA role emerged in the 1960s as a response to the shortage of physicians. The PA is licensed to practice medicine under a physician’s supervision. Physician Assistants practice in both the ambulatory and in-patient settings. Specific activities include: obtaining medical histories and conducting physical examinations; ordering and interpreting laboratory, radiological, and other routine diagnostic tests; performing routine procedures; managing simple conditions produced by infection or trauma; participating in the management of more complex illness and injury; and prescribing medication. Research evaluating APN and PA roles Published research evaluating APN and PA roles dates back to the late 1960s and early 1970s. The focus is gener