November 2008, Volume 35, Number 6
Leadership & Professional Development
Paula Klemm, PhD, RN, OCN®–Associate Editor
Building a Collaboration of Hematology-Oncology Advanced Practice Nurses
Part II: Outcomes
Anna D. Schaal, RN, MS, ARNP, Karen A. Skalla, MSN, ARNP, AOCN®, Tamsin J. Mulrooney, ARNP, PhD, OCN®, Diane Stearns, MSN, ARNP, and Ellen M. Lavoie Smith, PhD, APRN-BC, AOCN®
In Part I of this two-part article (Skalla & Caron, 2008), the authors described the process by which a group of advanced practice nurses (APNs) in a comprehensive cancer center developed a collaborative group practice to meet personal and professional challenges. Initially, the group consisted of nurse practitioners (NPs) who practiced in different disease-management groups (DMGs), each in collaboration with a lead physician, a single clinical nurse specialist (CNS) assigned to an inpatient oncology unit, and two NPs who worked in palliative care. Although the NPs worked closely with physicians in the DMGs, their annual evaluations were conducted by the department business manager. The NPs received a two-day orientation, after which they were expected to function independently in their respective DMGs. The CNS on the inpatient unit was given a one-month orientation by a peer, and her evaluations were provided by the nursing department. The APNs had few opportunities for collaborative research or education, and their participation in physician-sponsored projects went largely unrecognized. Using Tuckman’s model to facilitate group development, the APNs created a collaborative work environment designed to foster their professional growth and to meet the needs of the institution. This article describes the outcomes related to that newly formed collaborative APN group.
The process for meeting the goals set forth by the APNs was facilitated by a representative from the education department at the cancer center who had previously worked with the group in its development stages. Initially, the group determined that identity, unity, and recognition were priority needs. The needs were reflected in four overarching themes that focused on the outcomes the group wished to achieve: (a) identification as role models and leaders, (b) contributors to science, (c) contributors to caring, and (d) recognition for such contributions. The themes were used to define specific and measurable APN group goals and outcomes (see Table 1).
As role models and leaders, the nurses sought to be active contributors, not only to the science of hematology-oncology, but also to the caring that is fundamental to nursing. The contributions to science and caring reflect the unique duality of the APN role.
Theme: Role Models and Leaders
Goal: Institutional voice for the APN group
Outcome: Appointment of an APN director
An extensive process (described in Skalla & Caron, 2008) resulted in the appointment of an APN director (herself an APN) to represent the group. The director provides a unified voice for the group and participates in critical meetings that have direct influence on APN practice. For example, high-level administrative meetings address the challenges of determining clinic functioning, allocating cancer center resources, influencing how research is conducted, and strategic planning for the cancer center. The director helped the group meet those challenges by identifying concerns specific to APN practice and by negotiating for key resources necessary for optimal practice and satisfaction. She advocated for the appropriate use of APNs in research trials, cancer clinic triage nurses, and additional office space and support staff.
Goal: A formal group structure
Outcome: Weekly meeting
One key to the success of the APN collaboration is structured weekly meetings. The meetings serve many purposes, depending on the immediate needs of the group. The meetings are led by the director, who provides updates on cancer center activities that involve APNs. Topics that are addressed include continuing nursing education, support for clinical practice, brainstorming future projects, and networking with colleagues about clinical problems. Occasionally, no formal agenda is followed and the meeting provides time for peer support. Such meetings maintain group unity by providing a regular forum for direct peer collaboration.
Goal: Group cohesiveness
Outcome: Annual retreat
The group development process is rejuvenated by an annual two-day APN retreat attended by about 20 formal and informal (outside the hematology-oncology department) group members. The goal of the retreat is to provide clinical, personal, and professional development through peer support and networking, didactic lectures, and small group discussions. Team-building activities are an important aspect of the retreat. The utility of the endeavor is supported by the literature (Amos, Hu, & Herrick, 2005). Retreat topics are determined by group consensus during APN weekly meetings. For example, one retreat was devoted to the publication process; another focused on public speaking and was led by a professor of linguistics.
Theme: Contributors to Science
Goal: Acknowledgment to pursue academic endeavors
Outcome: Academic time
“Academic time” is an exceptionally valuable resource to facilitate academic productivity. Previously, designated time for academic pursuits was provided only to physicians. APN academic contributions were not recognized or valued enough to justify such time; in addition, clinical cross-coverage had never been negotiated to ensure that an individual could work uninterrupted.
The director intervened on behalf of the APNs and was able to secure academic time, based on the full-time equivalent of each individual. The time allotted is tied directly to productivity on an annual basis, using a point system. The system was developed by the APN director with the assistance of the section chief. Each academic endeavor is scored based on effort and time required for its completion. Credit is earned for activities such as publishing, doing research, performing committee work, making professional presentations, precepting, attending graduate school, submitting grants and obtaining funding, earning national certifications, and moderating support groups.
Academic time directly influences the ability of individuals to achieve academic goals. Since the APN directorship was instituted in 2000, the APN group has significantly contributed to the body of nursing knowledge. Examples of APN academic accomplishments include APN-led research and funding, more than 80 invited professional lectures annually, and numerous publications (e.g., papers, abstracts, book chapters). Three members of the group have received doctoral degrees. Other APNs have been members of administrative committees, organized and led patient support groups, and participated in community outreach projects.
Theme: Contributors to Caring
Goal: To be viewed as valued clinicians
Outcome: Education as clinical experts
The APN group offers an educational series for oncology nurses titled the “HEME/ONC Mini Course.” The course highlights the clinical expertise of each APN and is attended by nurses throughout the region. Specific disease pathologies, presentations, and treatments are reviewed, with relevant symptom management and nursing implications. Participants consider APNs from the group as valuable resources. In addition to those and other local lectures, many APNs present on regional and national levels in a variety of educational venues (see Table 2). As a result of such activities, APNs in the group have been invited to act as clinical consultants, based on their areas of expertise.
Goal: Specific APN systems
Outcome: New orientation program
Feedback from new and seasoned APNs indicated that a two- to three-day model of orientation was inadequate. The new orientation is tailored to individual learning needs and allows time for new APNs to understand institutional systems and develop a working relationship with their colleagues. Based on APN learning needs, a one- to three-month orientation program may be designed. The APN director coordinates the process and assigns a mentor for the orientation period. The program includes structured meetings to evaluate progress of new APNs and a competency evaluation at the end of orientation. The new process has resulted in increased APN satisfaction for orientees and seasoned members. Another positive outcome is that the past seven years have seen a less than 10% turnover. Four new members were hired after the process went into effect, and all have verbalized appreciation of the new system.
Outcome: A meaningful evaluation process
A new evaluation process, designed by APN group members and the director, changed the former and inadequate review process into a new format with three components. First, a peer review system is initiated, whereby each APN is evaluated by clinical and administrative team members and an APN peer. Feedback is compiled by the director for the annual review. Second, the APN completes an annual statement of short- and long-term goals. The goals are transformed into measurable objectives that can be used by the APN to focus energy and by the director to evaluate performance. Finally, the APN completes an “academic inventory” to quantify academic productivity. The process provides measurable outcomes that are used to give constructive feedback to the APNs. In contrast to the previous evaluation, the current system is meaningful and useful to the APN group.
Outcome: Changes in clinical practice systems
Since the inception of the APN collaborative group, the clinical practice style has changed dramatically. Originally, APNs were seen as “physician extenders.” Clinical triage and coordination were left to APNs, and physicians attended patient appointments. That arrangement did not satisfy the professional identity or functional needs of APNs. The APN director, speaking for the group, advocated for a change in practice. As a result, a triage level of RN was implemented. The triage nurses are directly responsible to their APN counterparts; they function as a team. The change has allowed APNs to spend more time in direct patient care and academic activity and has improved professional satisfaction of the APNs and their physician colleagues. In addition, it has improved patient care by providing faster access for patients who phone in with treatment-related questions. Patients have verbalized appreciation of quicker access to providers in emergencies, shorter call-back times, and more rapid refill orders on prescriptions.
Goal: To be seen as role models and leaders
Outcome: Representation on key institutional boards and committees
A number of leadership action plans have been initiated that place individual APNs in meetings with other institutional leaders. This has improved visibility and interdisciplinary communication and provided APN presence on the clinical cancer review committee and institutional review board. The APN director attends a monthly director group and other upper administrative meetings for budget development and strategic planning. She represents nursing directly within research groups in the cancer center. In addition, the leadership provided by the APN group illustrates modeling behavior for others throughout the medical center. For example, the new process for APN evaluations was included in the application for Magnet status and has been implemented in other sections in the medical center.
Outcome: Visibility in local, regional, and national leadership groups
The APNs now have increased professional visibility on a number of local, regional, and national boards and committees. Representation on the local level includes leadership roles in the local Oncology Nursing Society (ONS) chapter. Regional involvement includes membership on the state survivor coalition committee, state pain and end-of-life care initiatives, and the North East Regional Oncology Nursing Conference. Nationally, the APNs are leaders in a variety of ONS programs, including Putting Evidence Into Practice® resources, the Oncology Nursing Certification Corporation Advanced Practice Test Development Committee, special interest groups, the Leadership Development Institute, and the End-of-Life Nursing Education Consortium training program. APNs from the group also have led national committees, such as the Hemophilia Alliance, the ONS Educational Advisory Board, and Cancer and Leukemia Group B, and they have served as active members of other national groups, including the National Comprehensive Cancer Network. The group expanded its goals to include an international presence. One of the APNs currently chairs the International Society of Thrombosis and Haemostasis Nursing Sessions, where she has developed nurse-focused educational sessions that have been integrated into the international meeting agenda. Several APN group members routinely present abstracts at national and international conferences (e.g., International Psycho-Oncology Society meeting, ONS Congress and Institutes of Learning, International Neuropathic Pain Conference).
Outcome: Recognition through information access
Other strategic maneuvers designed to increase recognition of the APNs internally include having member names added to the electronic distribution lists for the cancer center “clinical provider list” and for the larger institution. This has focused attention on APNs as independent providers who require access to information on a level equal to that of their physician colleagues. As members of the distribution lists, APNs receive information about new hires, revenue updates, feedback on institution-wide surveys, financial and fiscal reports, administrative updates, institutional initiatives, and meeting minutes from the board of governors of the institution. In addition, the APNs have been added to the patient satisfaction and provider satisfaction surveys. This gives patients the opportunity to formally acknowledge the contributions of APNs in their health care.
Goal: Institutional recognition for APN achievements
Outcome: Annual awards ceremony
In 2004, the director of the group initiated an annual award ceremony to be held at the APN retreat. Each year, two APNs are recognized for their outstanding contributions: one for clinical excellence and caring, another for outstanding academic contributions. A monetary award is made toward a continuing nursing education account to recognize the winning APNs’ contributions and facilitate further professional development. The clinical excellence award is determined by nominations from clinical teammates and staff, such as clinical secretaries, nursing assistants, RNs, APN colleagues, physicians, and research personnel. The academic award is based on the academic productivity of an individual as measured by the academic accounting tool described earlier. The awards ceremony is attended by all of the APNs, the award winners’ physician partners, the director of the cancer center, and senior administrators of the medical center, including the chief executive officer and the vice president of professional nursing. The ceremony has provided recognition and reflected the value of the entire APN group to senior administration.
Outcomes of Purposeful Collaboration
The collaboration in the APN group spans seven years and has produced outcomes that have enabled the group to weather many internal and external changes in the healthcare system. Internal changes include increased demands to see more patients and the addition of new role changes in staff. External changes, such as revenue accountability, decreasing reimbursement for services, and changes in cancer center leadership, placed additional strain on clinic productivity and provider satisfaction. Stark (2006) suggested that to meet such challenges, APNs must become proactive in creating new roles and programs to meet the nation’s healthcare needs.
The outcomes described in this article highlight proactive aspects of growth and development of the collaborative APN practice group committed to healthcare excellence. Academic, clinical, and research achievements are facilitated in an intentionally formed collaborative group under the guidance of an effective leader. Cummings and McLennan (2005) suggested that having a leader to support, coordinate, and market change is critical to successfully integrate the APN role.
Inventive strategies have been developed by the group to improve patient care. A recent example is the “APN CARES” (Cancer and Related Events Survivorship) program developed under the APN director’s leadership. APN CARES is a multidisciplinary group providing physical, psychological, social, and spiritual support to cancer survivors. The successful outcome depended on recognition and implementation of changes by the APN group.
Challenges to Success
Measuring success has been a continuous challenge, and group development has been an ongoing process. Process outcomes often are described but may be difficult to quantify. Over the past few years, APN data have been separated from physician data, in an effort to report outcomes presented in this article. The current healthcare climate demands that providers see more patients in less time with fewer resources to keep healthcare costs down. In response to that demand, the “Relative Value Unit” system was adopted at the authors’ facility to measure productivity. It created competition in the clinic setting between MDs and NPs for patient billing and affected APN productivity numbers. Patients normally seen during office visits by NPs were then being seen by physicians as they tried to increase their productivity. APN productivity consequently went down. Time constraints also mean less time for APNs to interact with patients and peers, and the demands of a busy outpatient clinic make attending weekly APN meetings a challenge.
Increasing patient volume has put a premium on physical space. Some members of the APN group are physically isolated from their peers, which inhibits networking and collaboration. In addition, several rural oncology outreach sites have been established, placing some APNs in the community. That, too, can mean less time with peers.
Implications for Oncology Advanced Practice Nurses
Effective leadership for the collaboration of oncology APNs has been critical. The APN director established clinical time standards and functions as an advocate for APNs when conflicts occur as a result of incongruent role expectations. Communication, although difficult in the current healthcare climate, is equally important. Therefore, attendance at weekly meetings is a key to success.
The process by which collaborative practice was formed by the hematology-oncology APN group provided a structure to focus the energy and effort of each individual. Over time, the goals have changed and evolved as individuals have grown personally and professionally. The global group goals are guided by the APN director to ensure continued growth and development of the collaborative group. The outcomes illustrate the productive power behind an intentionally formed collaborative practice. The power ultimately advances nursing knowledge and science to improve the quality of care delivered to patients.
Amos, M.A., Hu, J., & Herrick, C.A. (2005). The impact of team building on communication and job satisfaction of nursing staff. Journal for Nurses in Staff Development, 21(1), 10–16.
Cummings, G., & McLennan, M. (2005). Advanced practice nursing: Leadership to effect policy change. Journal of Nursing Administration, 35(2), 61–66.
Skalla, K.A., & Caron, P.A. (2008). Building a collaborative hematology/oncology advanced nursing practice: Part 1. Oncology Nursing Forum, 35(1), 29–32.
Stark, S.W. (2006). The effects of master’s degree education on the role choices, role flexibility, and practice settings of clinical nurse specialists and nurse practitioners. Journal of Nursing Education, 45(1), 7–15.
Anna D. Schaal, RN, MS, ARNP, is a hematology nurse practitioner, Karen A. Skalla, MSN, ARNP, AOCN®, is an oncology nurse practitioner, Tamsin J. Mulrooney, ARNP, PhD, OCN®, was an oncology nurse practitioner when the article was written, Diane Stearns, MSN, ARNP, is hematology nurse practitioner, and Ellen M. Lavoie Smith, PhD, APRN-BC, AOCN®, is an assistant professor and director of hematology/oncology advanced practice nursing and the Cancer Survivor Program, all in the Norris Cotton Cancer Center at Dartmouth Hitchcock Medical Center in Lebanon, NH. Mulrooney now is a nurse educator for Genentech Bio-Oncology in the New England region of the United States. Mention of specific products and opinions related to those products do not indicate or imply endorsement by the Oncology Nursing Forum or the Oncology Nursing Society.
Digital Object Identifier: 10.1188/08.ONF.875-878