Preparing for Practice: Educating the New Oncology Advanced Practice Registered Nurse

2. Preparing for Practice: Educating the New Oncology Advanced Practice Registered Nurse Heather Brom, MS, RN, NP-C Margaret Quinn Rosenzweig PhD, FNP-BC, AOCNP Stephanie Schulte, MLIS

3. Outline Background (Brom) Fellowship Program (Brom) Embedded Librarian (Schulte) University-based education (Rosenzweig)

4. Background & Fellowship Heather Brom, MS, RN, NP-C

5. A Question for YOU

6. Which best describes your role? Clinician Educator Administrator Other

7. Background • The American Society of Clinical Oncology (ASCO) estimates a 48% increase in the demand for oncology services by 2020 • As it stands now, there will only be an increase in oncologists of 14% • Resulting in a projected shortage of 2,550 to 4,080 oncologists • The number of Americans 65 years and older is expected to double •81% increase in people living with or surviving cancer (Erikson, et al., 2007 & Erikson, et al., 2009)

8. Background – IOM Report • Institute of Medicine’s 2009 Ensuring Quality Cancer Care Through Oncology Workforce: Sustaining care in the 21st Century • In support of integrating and expanding the role of the APRN within a team-based model of care with the physician • Acknowledge that most NPs are trained in oncology after joining the practice •Great opportunity for APRNs to participate in survivorship care and symptom management

9. Background – SCPA • ASCO Study of Collaborative Practice Arrangements (SCPA) Goals: •Explore collaborative practice models between advanced practice providers and oncologists • National survey sent to oncology practices in spring 2009 • 226 practices participated in the survey • Assessed practice model, patient and physician satisfaction (Towle, et al., 2011)

10. Background – SCPA Results • Incident-to practice model is the most prevalent •Found patients, physicians, and APPs to be satisfied with APP practice • Practices using APPs who work with all of the practice physicians have a 19% higher productivity compared to practices where they work with specific physicians in the practice. (Towle, et al., 2011)

11. Background – IOM & ASCO • The 2009 ASCO SCPA and IOM report provide evidence that APRNs should be integrated into oncology practices

12. A Question for YOU

13. What percentage of NPs practicing in oncology received oncology-specific content in their NP training programs? 6% 16% 36% 56% (Nevidjon, et al., 2010)

14. A Question for YOU

15. What percentage of Advanced Oncology Certified Nurse Practitioners received graduate education focused in oncology? <5% 10% 21% 40% (Nevidjon, et al., 2010)

16. Post-Education Training • The Institute of Medicine’s (2011) Future of Nursing report recommends transition to practice programs • Oncology-specific internships date back to 1985 when the first one was developed in collaboration with the National Cancer Institute (NCI) Intramural Research Program for registered nurses • Now many of the 41 NCI Cancer Centers have oncology internships ranging from six weeks to one year (Childress & Gorder, 2012; Parchen, et al., 2008)

17. Residency Outcomes • For new registered nurses, residencies or internships lead to higher retention rates • Oncology specific internships have led to improved retention rates, increased RN competency, confidence, socialization, and satisfaction (Childress & Gorder, 2012)

18. A Question for YOU

19. How long does it take for a NP new to oncology to fell fully competent in his/her practice? 3-6 months 6-9 months 9-12 months 12-24 months (Nevidjon, et al., 2010)

20. NP Oncology Knowledge (Rosenzweig, et al., 2012)

21. Advanced Practice Oncology Fellowship Program • Based on experience at our institution, what is known in the literature about new oncology NP preparedness, and recommendations from the IOM’s Future of Nursing report, we received approval to initiate a year-long fellowship starting in fall 2013

22. Fellowship •Our goal: to have a robust advanced practice provider (APP) workforce that is specialty certified and has a rich foundation in EBP with an ability to integrate it into every day practice

23. Fellowship • Ten fellows accepted in inaugural class •All new graduate NPs •Average years RN experience = 3.2 (range 0-12) • Other experience (engineering, research, IT, public relations) •No oncology experience and limited role experience

24. Fellowship Orientation • Created unique orientation day that included: • Review of administrative structure • Logistics and expectations of the program • Tours of clinical areas • Quality indicators and NP involvement/impact • Compliance education • Overview of our professional practice model

25. Fellowship Clinical Rotations •September – December: •Rotated through various disease-based groups and experience both inpatient/outpatient, medical/surgical settings, as appropriate to the clinical area •January – August: •Fellows are experiencing 2-3 longer rotations that are based on their interests, compatibility with the clinical area, and anticipated need to fill a vacancy or add an additional NP to the team

26. Fellow’s Needs • Prior to starting the program, the fellows completed a needs assessment that was modified from The Bridging the Gap Workgroup’s 2012 publication •Fellows most comfortable with: •Performing a physical exam •Documenting in the EHR •Fellows least comfortable with: • Performing procedures • Providing survivorship care (Rosenzweig, et al., 2012)

27. Fellowship Education – Didactic • Bi-monthly, two hours •Presentations from various professionals within our hospital regarding oncology and clinical knowledge •Started with focusing on the elements for a cancer H&P and patient presentation skills •Goal of topics to be general to oncology practice – such as general symptom management and oncologic emergencies •Utilizing existing coursework in chemotherapy and disease-specific internal education

28. Fellowship Education – Lunch Sessions • Bi-monthly, two hours •Meant to be more casual •Opposite weeks of didactic education •Focus on: •APP role, including fostering the support system of the group – share common experiences – including successes and struggles •Multidisciplinary team roles – understanding their education and training, scope and responsibilities, and how the fellows can best collaborate with them to care for patients together

30. Fellowship Education – ONS Course • All fellows participated in the new 12 week online ONS Post-Master’s Foundation in Cancer Care for the Advanced Practice Provider •We were able to set up our own section of the course •Though it was asynchronous learning, we set bi-monthly milestones for course completion •Utilized our lunch and learn sessions during this time to have a course review •We went over frequently missed learning check points and other content that was felt to be difficult •Positive feedback from our fellows

31. Fellowship & Technology • Paperless schedules via Outlook •Created orientation books via iTunes University per specialty area and grant access to fellows to view •Posted lecture materials instead of printing slides •Utilized Apps like Notability which allow you to download slides and make comments on them •Created avenues for communication via social media •Closed Facebook group (with set ground rules) •Edmodo for posting self-reflection

32. Fellowship – Evaluation & Development • Created new onboarding tools •Short rotations included feedback tool by preceptor •Long rotations the fellows conduct self-evaluation, they record their strengths and weaknesses of the month, and make goals for the following month •Created preceptor development course that targeted preceptors for the fellowship

33. Fellowship – Short Rotation Assessments •Weekly assessments by preceptors on: • Professional Role • Interpersonal Relationships • Technical • Patient Care • Critical Thinking • Assessment categories: no opportunity, not demonstrating, learning, applying, or guiding

34. Fellowship – Long Rotation Assessments •Monthly self-assessment on: • Assessment Skills • Diagnosis, Planning & Intervention Skills • Patient Care Relationship & Professional Role • Self assessment categories: no opportunity, not demonstrating, learning, applying, or guiding • Monthly journaling: • Summarizing clinical experience • Areas of strength • Areas of needed improvement/goals for the coming month

35. Fellowship APP Fellow

36. Fellowship – Advantages • Dedicated time for education away from the clinical environment •Time is above a traditional onboarding process • Opportunity to try out several specialties prior to committing to one • Assigned mentor • 12 month onboarding compared to traditional 2-3 month for a new hire

37. Fellowship – Measuring outcomes • Ohio State University IRB approval to study fellowship cohort curing the program and follow them for 24 months • Outcomes include perceived autonomy, job satisfaction, belief in and implementation of evidence based practice, and cost-effectiveness of the program.

38. Embedded Librarian Stephanie Schulte, MLIS

39. A Question for YOU

40. What has been your primary experience working with a librarian on an evidence based practice project? • I’ve never worked with a librarian on an EBP project. • The librarian did the literature search for me. • The librarian taught me how to search databases for an answer to my question. • The librarian taught me how to critically appraise articles. • The librarian helped me articulate my question, learn to search and/or performed some of the search for me, and helped with the appraisal and synthesis of evidence. • Other

41. Embedded Librarian in APP Oncology Fellowship • Health Sciences Library conducted a request for proposals grant awarding embedded librarian • Fellowship awarded embedded librarian for up to 20 hours per week for 12 months • Librarian had years of experience teaching nurses, nursing students and medical students evidence based practice

42. What is an embedded librarian? • Disparity in working definitions • Compare to embedded journalists • Cultural integration into a clinical or academic unit to provide customer-driven, specialized, and complex information services • Distinctions in terminology: informationists versus clinical librarians versus embedded librarians

43. Initial Vision for Embedded Librarian within APP Fellowship • Guide APPs in developing and conducting EBP projects • Refresh curriculum in collaboration with nursing education • Provide real time evidence in the context of clinical interdisciplinary team • Connect with patients and families regarding searching high quality info resources

44. Actual Embedded Librarian Role within the APP Fellowship • Provided expert literature support during planning processes • EBP workshop with fellows • Support for EBP projects: preliminary investigation on questions, mentoring in addition to CNS mentors, guidance and motivation throughout project • Mentoring critical thinking by application of EBP process • Built relationships with oncology nursing administrators

45. Examples of Embedded Librarian Work

46. Examples of Embedded Librarian Work

47. Impact and Challenges • Statistics • Clinical rounds • EBP realities • Patient education • Working within a system’s established culture

48. Resources for Developing an Embedded Librarian Program • If you have a library, contact them first to begin discussions. • If you don’t have a library, consider recruiting through the Medical Library Association: mlanet.org. • Consider consulting with established programs for guidance.

49. Practice Issues in Oncology Nurse Practitioner Practice Margaret Quinn RosenzweigPhD,FNP-BC,AOCNP University of Pittsburgh School of Nursing R25 - CA148050-03

50. Original Curriculum University of Pittsburgh • Multiple sources of input • Nurse practitioner educational criteria – ONS and ACS • Oncology advanced practice nursing • 48 credits – 600 clinical hours • 9 credit/30 week curriculum – 400 clinical hours oncology • Traditional didactic lectures • Clinical with MD/NP/PA preceptors • Little opportunity for faculty feedback • Good Outcomes – Students felt prepared, employers rated highly prepared • No longer possible