1. The Role of the Nurse Practitioner in an Ambulatory Oncology Setting Pamela Hallquist Viale, RN, MS, CS, ANP, AOCNP Oncology Nurse Practitioner Camino Medical Group Assistant Clinical Faculty, UCSF Dept of Physiological Nursing

2. Specialty Nurse Practitioners An idea that is starting to change practiceAn idea that is starting to change practice NP’s firmly established in primary care and women’s health; specialty NP’s have grown in numbers over the last ten yearsNP’s firmly established in primary care and women’s health; specialty NP’s have grown in numbers over the last ten years Many NPs are adult or family NPs; once trained they get additional training in specialty areasMany NPs are adult or family NPs; once trained they get additional training in specialty areas There are 23 specialty NP educational programs presently in the USThere are 23 specialty NP educational programs presently in the US Young, T (2005). Utilizing oncology nurse practitioners: a model strategy. Community Oncology, 2, 218-224.

3. Differences Between NP and Physician’s Assistant NP must be a nurseNP must be a nurse Nursing model used as primary training; medical classes serve as adjunctNursing model used as primary training; medical classes serve as adjunct NPs are trained as specialists (adult, pediatrics, ect)NPs are trained as specialists (adult, pediatrics, ect) Nursing Board oversees NPsNursing Board oversees NPs NPs need to have a collaborating physician, but may practice independentlyNPs need to have a collaborating physician, but may practice independently All NPs are at the Master’s level; as of 2015 this may change to doctorate level onlyAll NPs are at the Master’s level; as of 2015 this may change to doctorate level only PA can come from many backgrounds Medical model is used in PA training; trained in general medicine State Board of Medical Licensure oversees PAs All PAs must have an MD in a supervisory role PA students have more hours of supervised clinical practice in training PA can be at bachelor level; this will change to MS in 2006 Young, T (2005). Utilizing oncology nurse practitioners: a model strategy. Community Oncology, 2, 218-224.

4. Prescriptive Authority In California, it is called “furnishing”In California, it is called “furnishing” NPs are certified by all but six states to prescribe medicationsNPs are certified by all but six states to prescribe medications In California, NPs now have the ability to write for Schedule II-V medications as of 2005In California, NPs now have the ability to write for Schedule II-V medications as of 2005 NPs are also certified by the ANCC and ONS (AOCNP)NPs are also certified by the ANCC and ONS (AOCNP) Young, T (2005). Utilizing oncology nurse practitioners: a model strategy. Community Oncology, 2, 218-224.

5. Schedule II Prescribing

6. Frequently Asked Questions Regarding NP Practice Do my charts need to be signed by an MD? The nursing practice act does not require MD countersignature, but insurances may require itDo my charts need to be signed by an MD? The nursing practice act does not require MD countersignature, but insurances may require it How often do I update my standardized procedures? Frequently enough to ensure that patients are receiving appropriate careHow often do I update my standardized procedures? Frequently enough to ensure that patients are receiving appropriate care Can an NP request and sign for drug samples? YesCan an NP request and sign for drug samples? Yes In my furnishing procedure, do I need to list the drugs and devices that can be furnished or may I use categories? The law requires the identification of the drugs and devices in standardized procedure or protocol. You may not use drug categoriesIn my furnishing procedure, do I need to list the drugs and devices that can be furnished or may I use categories? The law requires the identification of the drugs and devices in standardized procedure or protocol. You may not use drug categories Frequently Asked Questions Regarding NP practice (Revised 12/2004). Board of Registered Nursing, State of California

7. Standardized Procedures Standardized procedures are the legal mechanism for registered nurses, nurse practitioners to perform functions which would otherwise be considered the practice of medicineStandardized procedures are the legal mechanism for registered nurses, nurse practitioners to perform functions which would otherwise be considered the practice of medicine Provides the system with satisfactory evidence that the nurse meets the experience, training, and/or education requirements to perform the functionsProvides the system with satisfactory evidence that the nurse meets the experience, training, and/or education requirements to perform the functions An explanation of standardized procedure requirements for nurse practitioner practice (12/1998). Board of Registered Nursing

9. Roles of Oncology Nurse Practitioners Practice Partner: private, academic, inpatient or outpatientPractice Partner: private, academic, inpatient or outpatient Administrative Partner: documentation and codingAdministrative Partner: documentation and coding Research Partner: enrolling patients, writing study protocolsResearch Partner: enrolling patients, writing study protocols Liaison: between nurses and physicians and patients and physiciansLiaison: between nurses and physicians and patients and physicians Triage Nurse: taking patient phone calls, seeing all walk-in patients, performing chair rounds in infusion roomTriage Nurse: taking patient phone calls, seeing all walk-in patients, performing chair rounds in infusion room Young, T (2005). Utilizing oncology nurse practitioners: a model strategy. Community Oncology, 2, 218-224.

10. Example of NP Role in Oncology Ambulatory Setting See treatment patients while on chemotherapy; write orders for subsequent chemotherapy treatments See walk-ins or sick calls See stable follow-up cancer patients

11. Example of an NP Role in the Ambulatory Setting Does NOT write initial chemotherapy orders or change chemotherapy orders independently (except for those established by protocol: example AI’s)Does NOT write initial chemotherapy orders or change chemotherapy orders independently (except for those established by protocol: example AI’s) Patients with urgent problems or who appear unstable reported to MDPatients with urgent problems or who appear unstable reported to MD

12. Common Problems Encountered in Ambulatory Practice DVTDVT Herpes ZosterHerpes Zoster CAPCAP Neutropenic FeverNeutropenic Fever HSRHSR AbscessAbscess Diarrhea/ConstipationDiarrhea/Constipation With standardized procedures/protocols, NP’s can manage these and like problems, bringing in the MD when appropriate

13. Special Skills ONP’s Bring to Oncology Setting Psychosocial CarePsychosocial Care Patient EducationPatient Education Performing ProceduresPerforming Procedures Young, T (2005). Utilizing oncology nurse practitioners: a model strategy. Community Oncology, 2, 218-224.