Abby Fyfe, Oncology Clinical Nurse Consultant, Macquarie University Hospital
Private Sector Representative, ANZ-LCNF Steering Committee
Recently completed a Master of Cancer and Haematology Nursing
As an Oncology Clinical Nurse Consultant (CNC), I strive to provide patient-centred care to optimise outcomes for cancer patients. Progression of my career would be pursuing the Oncology Nurse Practitioner (ONP) role, an advanced practice position working both autonomously and collaboratively conducting expert patient assessment, diagnosis and management. To help me decide whether to pursue this progression, I explored the literature to determine how this role has been established, explore its challenges and examine the potential benefit for cancer services.
It has been suggested that the NP role was first established to fill doctor shortages in rural settings. The role has since grown to be widely accepted for chronic and complex patient care in all settings (MacLellan et al., 2015a). They have the ability to diagnose, order imaging and prescribe medications within their scope of practice in a shared-care arrangement with a medical team and are a key part of the multidisciplinary team (MDT) to meet diverse patient needs (MacLellan et al., 2015a). A cross-sectional survey of Australian residents conducted by Dwyer et al. (2021) found an overwhelming acceptance of the role and 86% of residents with a chronic or complex condition were willing to have an NP manage their care.
The establishment of the NP role has not come without its challenges. The arguably confusing and bureaucratic endorsement process has led to many delays in role commencement (MacLellan et al., 2015b). The uncertainty of how the role fits into the healthcare team hierarchy, reports of professional jealousy and poor managerial support causes unnecessary power and politics that new NPs feel ill prepared to negotiate (MacLellan et al., 2016). However, despite early medical resistance of the role, doctors have become NP’s biggest supporters and can see the positive impact on patient care (MacLellan et al., 2015a, 2016). It is clear from this that an essential ingredient of the success recipe for establishment and maintenance of an NP role lies with strong medical and executive support and a clear scope of practice (Campbell et al., 2016; MacLellan et al., 2015a, 2015b, 2016).
ONPs are the pinnacle of clinical expertise in oncology from diagnosis, through treatment, survivorship and end-of-life care. The role provides expert patient management in collaboration with the broader medical and support services team, bridging the gap between medical and nursing care and provides a cost effective, specialised service to patients (Bowyer & Schofield, 2014). In some facilities, the ONP provides a specialised assessment clinic for unwell patients on anti-cancer treatment, showing improvements in patient assessment and outcomes and a reduction in hospital and ED admissions (Cox et al., 2013; McCavery, 2020; Oatley & Fry, 2020). Oatley and Fry found that without the ONP intervention, 18% of patients would not have reported their symptoms, which is quite a frightening statistic. In the broader cancer context, the ONP role has also been shown to improve efficiencies, decrease intervention delays and improve intra-, inter- and multi-disciplinary communication and collaboration (Bowyer & Schofield, 2014; Campbell et al., 2016; Cox et al., 2013; McCavery, 2020; Oatley & Fry, 2020). Facilities with strong nursing leadership, which the ONP represents, may even reduce the cancer impact in the Australian community (Anderiesz et al., 2006).
With the ONP ability to prescribe medications, they must be diligent across all aspects of medication management. A literature review conducted by Fong et al. (2017) found that 78% of NPs confidently prescribe regularly. The ONP will have a scope of practice document outlining medications they are authorised to prescribe, will develop policies and procedures relating to medication management and assist with relevant training of junior staff (Scanlon et al., 2016). They are required to develop individualised care, have comprehensive medication knowledge, determine therapeutic requirements, verify treatment suitability and consider costs and access when prescribing medications in collaboration with a medical team (NMBA, 2021). As the ONP works closely with the hospital and community MDTs, has complete patient oversight, combines advanced nursing practice with medical skills, promotes health and self-care, holistically assesses, can navigate the health system and considers non-medical interventions, they are well placed to safely and effectively assess, diagnose and provide therapeutic interventions for cancer patients (Campbell et al., 2016; McCavery, 2020; Pirret et al., 2015).
The ONP role is an advanced practice nursing role at the peak of clinical care. There are documented challenges with the transition into such a role that would need to be negotiated. However, facility support and a clear scope of practice, as well as a medical ‘champion’ from the outset would help to navigate potential barriers. The obvious benefits, not only to patients, but also to the facility and the healthcare team, outweigh the possible difficulties in establishing the role, making pursuit of an ONP position well worth consideration.
- Anderiesz, C., Elwood, M., & Hill, D. (2006). Cancer control policy in Australia. Australia and New Zealand Health Policy, 3(1). https://doi.org/10.1186/1743-8462-3-12
- Bowyer, S., & Schofield, D. (2014). The role of oncology nurse practitioners in current oncology practice and lessons for Australia. Medical Journal of Australia, 200(7), 382-384. https://doi.org/10.5694/mja13.10535
- Campbell, J., Cusack, L., & Green, C. (2016). The role of the oncology nurse practitioner in the clinical management of febrile neutropenia. The Australian Journal of Cancer Nursing, 17(1), 20-25. https://doi.org/10.3316.informit.431836186105640
- Cox, K., Karikios, D., Roydhouse, J., & White, K. (2013). Nurse-led supportive care management: A 6-month review of the role of a nurse practitioner in a chemotherapy unit. Australian Health Review, 37(5), 632. https://doi.org/10.1071/ah13069
- Dwyer, T., Craswell, A., & Browne, M. (2021). Predictive factors of the general public’s willingness to be seen and seek treatment from a nurse practitioner in Australia: A cross-sectional national survey. Human Resources for Health, 19(1). https://doi.org/10.1186/s12960-021-00562-7
- Fong, J., Buckley, T., Cashin, A., & Pont, L. (2017). Nurse practitioner prescribing in Australia: A comprehensive literature review. Australian Critical Care, 30(5), 252-259. https://doi.org/10.1016/j.aucc.2016.11.003
- MacLellan, L., Higgins, I., & Levett-Jones, T. (2015a). Medical acceptance of the nurse practitioner role in Australia: A decade on. Journal of the American Association of Nurse Practitioners, 27(3), 152-159. https://doi.org/10.1002/2327-6924.12141
- MacLellan, L., Higgins, I., & Levett-Jones, T. (2015b). A game of snakes and ladders: Negotiating the ‘ups and downs’ of endorsement as a nurse practitioner in Australia. Contemporary Nurse, 50(2-3), 139-148. https://doi.org/10.1080/10376178.2015.1101351
- MacLellan, L., Levett-Jones, T., & Higgins, I. (2016). The enemy within: Power and politics in the transition to nurse practitioner. NursingPlus Open, 2, 1-7. http://dx.doi.org/10.1016/j.npls.2016.01.003
- McCavery, A. (2020). A nurse practitioner-led model to implement and deliver unscheduled emergency cancer care. The Journal for Nurse Practitioners, 16(4), 271-275. https://doi.org/10.1016/j.nurpra.2019.12.020
- Nursing and Midwifery Board of Australia. (2021). Nurse practitioner standards for practice. https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/nurse-practitioner-standards-of-practice.aspx
- Oatley, M., & Fry, M. (2020). A nurse practitioner–led model of care improves access, early assessment and integration of oncology services: An evaluation study. Supportive Care in Cancer, 28(10), 5023-5029. https://doi.org/10.1007/s00520-019-05292-0
- Pirret, A., Neville, S., & La Grow, S. (2015). Nurse practitioners versus doctor’s diagnostic reasoning in a complex case presentation to an acute tertiary hospital: A comparative study. International Journal of Nursing Studies, 52(3), 716-726. https://doi.org/10.1016/j.ijnurstu.2014.08.009
- Scanlon, A., Cashin, A., Bryce, J., Kelly, J., & Buckely, T. (2016). The complexities of defining nurse practitioner scope of practice in the Australian context. Collegian, 23(1), 129-142. https://doi.org/10.1016/j.colegn.2014.09.009