Can advanced practice nurses find hospice jobs?
Can advanced practice nurses find hospice jobs?
Extra training could support team, physicians
Hospice and palliative care nursing increasingly is recognized as a distinct specialty, with its own discrete body of knowledge, guidelines, and standards. (See related story, p. 93.) Some 3,339 nurses have been certified by the National Board for Certification of Hospice Nurses in Pittsburgh since its exam was introduced in 1994. But can this specialty make room for the even more highly specialized role of the advanced practice nurse also known as nurse practitioner or clinical nurse specialist? Few if any nursing education programs now prepare advanced practice nurses in hospice or palliative care. But a few intrepid nurses are trying to push the profession’s boundaries and create a role for themselves in hospice.
Tom Grothe, NP, a former hospice nurse in San Francisco who recently obtained his Adult Nursing Practice credential in medicine with a minor in HIV care, has been seeking a hospice job that would allow him to practice this role. A palliative care nurse practitioner could be invaluable to hospice teams and to attending physicians, Grothe says. "For example, in a residential facility where the physician doesn’t come to visit very often, my fantasy job was to function almost like an associate medical director."
However, Grothe was not able to find such a position, and he will soon start work as an internal medicine nurse practitioner at the South San Francisco medical center of a Kaiser Permanente HMO.
Why was it so hard to find such a position in hospice? "Advance practice nursing in hospice is a very new concept. It’s just not done," Grothe explains. "Therefore, we need to better articulate what we’re doing that’s different than RNs."
Unfortunately, says Susan Mann, RN, CRNH, of Wichita, KS, president of the Hospice Nurses Association, "a lot of agencies don’t value nursing staff in general and don’t see the value of the nurse practitioner. To them, a nurse is a nurse is a nurse. Another issue is cost, and it adds a level of complexity to what is already a very complex business," Mann says.
"With so many other pressures coming to bear on hospice, this is just not a priority," adds Patricia Berry, PhD, RN, CRNH, CS, a former hospice nurse in Madison, WI, who now teaches cancer nursing at the University of Wisconsin-Madison. "I don’t think people understand what a nurse practitioner does. I also don’t think the hospice movement realizes it could use the nurse practitioner on behalf of the medical director working under protocol [standing medical orders], for instance, to review the prognosis of patients referred to hospice. In Wisconsin, advanced practice nurses can get prescribing privileges and hang out their shingles. I can actually bill for my services, the same as a physician," Berry adds.
"There is an additional body of expertise that a nonadvanced practice nurse could obtain, certainly, but that is part of the role of clinical nurse specialists and nurse practitioners." This role combines research, education for other nurses, consultation on difficult cases, and actual clinical practice. "One of our biggest roles is to act as role model for excellence in nursing practice and support RNs so they can improve their clinical practice. As a hospice nurse, you’re out there all alone; you have to practice at an excellent level to do hospice right. To reach that level, you need to be mentored," Berry adds.
The term advanced practice nurse (APN) is being used to cover the jobs of nurse practitioner, clinical nurse specialist, and nurse midwife. This role is being clarified for "nurses who have acquired the knowledge base and practice experience to prepare themselves for specialization on one focus of the field of nursing, for expansion of skills within a practice area, and for advancement by means of graduate education in nursing,"1 explains Jeanne M. Weggel, BSN, of the University of Wisconsin, Eau Claire, writing earlier this year in the Hospice Journal.
Kim Kuebler, MN, RN, CRNH, APRN, developed such a role at Connecticut Hospice in Branford, where she consulted on difficult cases, made home visits, admitted patients to the hospice inpatient facility, communicated with attending physicians, and brought her advanced assessment skills and medical knowledge to the support of physicians and nurses. "I was able to provide a more comprehensive plan of care in support of the nursing case manager," she explains. "I also developed outcomes measures so that we could start to test and prove the efficacy of the role in terms of cost, pain and symptom management, and quality."
Kuebler recently left Connecticut and returned to Clare, MI, where she plans in September to launch an independent practice as an adult nurse practitioner specializing in end-of-life care. She is remodeling a suite of offices, and plans to consult with area physicians and hospices and apply for admitting privileges at local hospitals perhaps even employ home care nurses. She will also be able to directly bill Medicare and Medicaid for her services, the same way physicians do.
"My training has opened up new avenues in assessment and knowledge of pharmacology and pathophysiology," she says. "The more knowledge you have, the more power to have to advocate for the patient. A lot of nurses just don’t get it, but they think they do. The nurse practitioner, being a middle person between the RN and the physician, can bridge that lack of knowledge."
Reference
1. Weggel, JM. Palliative care: New challenges for Advanced Nursing Practice. Hospice Journal 1997; 12:43-56.
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