Abstract
Introduction
Nurse practitioners have become a mainstay in both the hospital and outpatient setting. Despite their routine participation in clinical care, the decision to incorporate nurse practitioners (NPs) into a vascular medicine practice can be challenging. It is important to first identify the needs of the program and determine which of these may be addressed by hiring an NP. Nurse practitioners can be utilized in a variety of settings, including inpatient, outpatient, specialty clinics, and research. This article provides insight into the incorporation of nurse practitioners into a university-based vascular medicine program and a community-based vascular medicine program.
Program development
University-based program
The NP role within the vascular medicine program at Vanderbilt University Medical Center (Nashville, TN, USA) is a new position within a recently organized program. The NP sees patients in both the inpatient and outpatient settings, but the majority of time is spent in the outpatient setting in collaboration with three vascular medicine physicians. The NP assists with patient evaluation, note writing, and treatment planning, and may see patients independently in the clinic setting. The NP is currently developing a more focused practice in venous thromboembolism, which includes consultation for leg swelling, deep vein thrombosis, pulmonary embolism, and inferior vena cava filter management. A second area of interest is the chronic outpatient management of aortic aneurysm and dissection. In the inpatient setting, the NP serves as the point of contact and initial evaluation for inpatient consultation during the work week. Once evaluated, the patients are reviewed with one of the attendings, the plan is developed, and the NP coordinates the communication between the vascular team and requesting service. The NP continues to follow the patients as needed, obtaining physician input on an as-needed basis. Additionally, the NP has administrative responsibilities, including coordination of the vascular medicine consult schedule and outpatient clinic participation of the rotating cardiology fellows during their vascular rotation, and a quality improvement project. The NP within the university-based vascular medicine program is able to bill independently within the outpatient setting. In the inpatient setting, typically an attending physician is required to see the consult in conjunction with the NP. The NP’s role continues to evolve as knowledge and experience is gained to take on more responsibilities.
Community-based program
The community-based program at OhioHealth Heart & Vascular service line (Columbus, OH, USA) has a more mature NP program than Vanderbilt. There are six NPs who collaborate with six peripheral vascular interventional physicians and two vascular medicine physicians. Although the physicians maintain their own outpatient clinical practices, their time is restricted due to the amount of time they are needed in the interventional/procedural labs and on rounds. Implementation of the NP role was necessary to facilitate the day-to-day inpatient management of the service, provide more efficient response times for consultations, and staff outpatient and outreach clinics. The NP also plays a significant role in the management of the critical limb care center (CLCC), which houses the hyperbaric unit, wound care center, and one of the vein centers. Within the CLCC, an NP sees patients with urgent needs within 24 hours and arranges intervention if necessary, manages the patients receiving hyperbaric oxygen therapy, and staffs the wound and vascular medicine clinics. NPs at OhioHealth can bill independently, both the inpatient and outpatient setting. NPs see inpatient consultations initially, following which the attending physicians staff, and bill for, the consult. Subsequent inpatient follow-up visits, however, are billed by the NPs. In the outpatient setting, the NPs bill for all patient visits. Although this is not a university-based program, the NPs are involved with a number of research activities. As investigators at the OhioHealth Research and Innovation Institute, all vascular NPs are required to complete research ethics and compliance training. Thereafter, they serve as the site principal or subinvestigators, assist in data collection, conduct study follow-up, and also function as co-authors on journal articles and abstracts. Finally, the NPs are involved in many aspects of quality improvement and program development.
Recruitment
Finding NPs to fulfill the needs of a vascular medicine practice can be difficult, particularly with the broad range of responsibilities and knowledge required. Recruiting experienced NPs or those with transferable skills can aid in a more rapid track to independence. NP students who have completed a rotation with a vascular program are good resources for recruitment. For outside candidates, NPs can shadow current NPs after they interview to allow a better opportunity for both parties to assess their fit with the program.
Onboarding and curriculum development
Once hired, onboarding should ensure a minimum set of skills and knowledge is held by all members of the team. Based on the niche to be filled, the training can then be customized to meet the needs of the NP, or the exposure broadened as needed. It is important to begin with an assessment of the NP’s knowledge base and create a specific training program for efficient skill and knowledge acquisition. Much of the training is through on-the-job experience under direct supervision with the collaborating physicians or peer NPs, similar to the medical training process. In addition, the NP must acquire more formal instruction from written sources including book chapters and journal articles. The NP should be provided observation time in areas to which he or she will routinely refer patients, including the angiography suites, the vascular laboratory, and observations of vein procedures and wound care. Finally, support should be provided for NPs to attend vascular conferences. Examples of such meetings include Vascular Interventional Advances (VIVA), which has a dedicated track for allied health professionals such as NPs. Another example includes attending the Society for Vascular Medicine (SVM) annual meetings, which has been beneficial for the NP. Recently, the advanced practice providers (APP) spoke on a panel regarding their specific role within their practices. Additionally, NPs are encouraged to submit case reports and posters. SVM has recently announced a new APP course (see below), which will be held in December, 2019. APPs are welcome to become members of the SVM. Finally, NPs may also benefit from attending Society of Vascular Nursing (SVN) annual meetings, along with involvement within the society in order to collaborate and incorporate vascular NPs within the SVM and SVN.
To keep NP staff up to date, the importance of evidence-based practice must be stressed along with the method to apply it to their practice. In a university-based program, NPs might have access to journal clubs or grand rounds related to their specialty. Regardless, encouragement to read clinical trials, become more comfortable understanding the studies, and then applying the data to everyday practice is essential for continued growth.
Goal-setting
Identifying and setting clear goals for the NP, the collaborating physician, and the program is essential to ensure success. Failure to set reasonable goals can result in feelings of frustration and discouragement; maybe even resignation. The physicians must be committed to invest the time required to provide the education and training needed to foster the NP’s success within a vascular medicine program. Frequent evaluations of the process should be conducted to determine if the NP is staying on track for meeting the goals set for him or her and whether the necessary support is being received from his or her physician or peers.
Sustainability
An NP’s first year in a vascular medicine practice consists mostly of learning a very complex field and applying that knowledge to the clinical setting while gradually building independence. As the NP gains confidence and independence, he or she will start to see him/herself as less of a trainee and more as part of the team. Encouraging involvement in professional societies such as the SVM and SVN will provide a sense of membership within the field as well as allow the NP to develop networks beyond the walls of his or her own institution. Becoming a preceptor and working with residents fosters an atmosphere of continual learning and collaboration. Finally, collaborating with physicians who are supportive, inclusive, approachable, and accessible sets the tone for a sustainable and successful work environment.