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Interviews with Advanced Practice Nurses: A Day in the Life.

Questions Regarding the APN Role

As a nephrology nurse who has recently started in a master's nurse practitioner (MSN/NP) program, I am being asked by nephrologists how an advanced practice nurse (APN) can be used effectively in their practice. I have told them what I know but that I am just learning, and they are more interested in specifics. I have spoken to some APNs who presently are working in nephrology settings, but I would like some more input as to what is being done in other areas of the country, outside of where I live in Southern California.

What I would like to know is the following:

Is your practice based in the outpatient setting (the clinic and the office), and/or do you cover hospital patients? What types of services do you provide for your patients? How is billing for services handled?

Any information you can provide would be greatly appreciated. Right now I'm finding all of this a little overwhelming.

Sherry L. Child, BSN, RN, CNN Kaiser Permanente Riverside, CA

Descriptions of Various APN Roles

Editor's Note: The following responses were furnished by advanced practice nurses (APNs) from all over the United States in response to the above questions posted on the ANNAlink Advanced Practice ListServe.

Andrea K. Easom, MNSc, APN, CS, CNN

The Renal Physicians Association (RPA) and American Society of Nephrology (ASN) have a joint task force that is examining collaborative practice models. Chris Chmielewski and I are both members of the task force representing ANNA. Reimbursement data are scarce, since much of the work performed by APNs in chronic dialysis units is covered by the MCP (monthly capitated payment) that nephrologists receive. If any APNs reading this have actual data on their billing and reimbursement, please contact either Chris or myself through the ANNA National Office at (800) 203-5561.

The ANNA National Office can provide you with the ANNA Position Statement on Advanced Practice, the RPA/ASN/ANNA Position Paper, and the Scope of Practice for Nephrology APNs. The position papers are also on the ANNAlink under "Our Position." The APN SIG is currently working on Standards of Practice for Nephrology APNs.

I have two master's degrees, one in applied psychology and one in nursing sciences. Since my undergraduate nursing degree was an associate science degree (ASN), I completed a bridge program prior to acceptance into my graduate nursing program. My clinical specialty is family practice. I hold national certification as a family nurse practitioner (ACNN) and as a nephrology nurse (CNN). In my state (Arkansas), I must hold an advanced national certification in my clinical specialty to be licensed as an APN. A master's degree in nursing in a defined clinical area, advanced national certification, and certification as a CNN are the credentials ANNA recommends for APNs working in nephrology. ANNA recognizes that 2 years of nephrology experience and completion of 30 hours of continuing education courses in the fundamentals of nephrology nursing are required to sit for the CNN examination. So for APNs new to nephrology, it is recommended that they become nephrology certified (CNN) as soon as they are eligible. I have 23 years of nephrology nursing experience, with the last 3 in my advanced role.

Our dialysis unit and clinics are together and our nephrologists have offices at the university. I am based at the dialysis unit/clinics, and I manage 100 dialysis patients (80 hemodialysis and 20 peritoneal dialysis [PD]) with the support of 3 nephrologists and 5 renal fellows. Our physicians are assigned to patients by dialysis shift. Each fellow has one shift. The medical director has one shift, and the fellows round weekly while the staff nephrologist rounds with the fellow once a month. I round with all first-year fellows weekly. I cover for any physicians when they are gone. I also handle patient problems for all MDs when they are not in clinic/unit and I work with the staff regarding problems, including development of continuous quality improvement (CQI) teams. I also sit on the vascular access committee and work directly with either our surgeon or interventional nephrologist for vascular access problems. We have an active bone marrow transplant program that usually has 8-10+ transient hemodialysis patients monthly. I write probably 98% of the initial hemodialysis orders for all patients, including transient patients. Since most of the care in the unit falls under the Medicare Capitated Payment (MCP), I only bill for procedures, such as cath removal and antithrombolytic administration, as appropriate.

We also follow more than 300-plus conservatively managed patients, many of whom are pre-ESRD. In November, I started a weekly half-day diabetes/CRF clinic with one nephrologist and a hypertension clinic with another. I also handle PD patients' episodic problems any time other than their monthly or every other month routine visits, see any "drop-in" patients, and help with clinics and cover for our IV therapy patients (OKT3[R], INFed[R], and Cytoxan[R]). I assist with pre-ESRD classes twice a month, both in basic and advanced courses. We have an active clinical research program with numerous studies that require my intermittent attention. I also address nondialysis problems of hemodialysis patients in the clinic rather than the dialysis unit for both billing and privacy reasons. I do histories and physicals (H&Ps) and the primary care, especially smoking cessation and sexual dysfunction. I bill for all clinic visits, and I have Medicare, Medicaid, Blue Cross/Blue Shield, Qual Choice, and Champus numbers. United Health refuses to give APN numbers in Arkansas, so I do not see their patients.

I have hospital admitting privileges and admit, but do not follow patients once they are hospitalized. I consult per my collaborating physician's request, usually in difficult social situations where I am the one who may have a rapport with the patient/family. In time, we hope to have an APN for acute care and we also plan to hire another APN for the unit/clinic.

All in all, my days are full. Our physicians are great and we make a terrific team! The key is trust and good communication. Each physician is a little different to work with. Some I e-mail and others I call or leave a note on the chart, depending on the problem and the urgency.

APNs MUST recognize what they don't know, and seek out their collaborating physician for confirmation and/or diagnosis in these cases. After all, we are not physicians, and need to feel comfortable with our assessment of the abnormal and the appropriate referral. Of course, I must also note that we have EXCELLENT staff nurses. I feel that APNs are in the position to be both nurse and patient advocates. Without the support of the nursing staff, my job would be much more difficult.

Andrea K. Easom, MNSc, APN, CS, CNN Instructor, Nephrology Division Department of Medicine University of Arkansas for Medical Sciences Little Rock, AR

Debra Castner, MSN, CNN, NP-C

I work full time as an APN in private practice with 7 nephrologists. I am responsible for 4 outpatient centers where I do monthly reviews, take care of episodic health problems, and perform procedures (internal jugular removal, PD catheter repairs, suturing, incision and drainage of infected exit sites, and femoral catheter insertions). I work with pre-ESRD, hemodialysis, and PD patients. I am a member of various committees, and do minimal office work.

I do not see many patients in our office because we only provide consults for nephrology (no internal medicine). I will perform follow-up visits for hypertension or pre-ESRD if needed. Even though I cannot bill for monthly visits (because nephrologists receive a monthly capitated payment), I do bill for nondialysis-related visits and procedures. A key role that I provide is to free up physicians to do consults and hospital work. Physicians will conduct bimonthly chart reviews with me and make visits with patients, a system that make both patients and staff happy. I will also make the first call-back to patients and families who call the office with questions or concerns.

You need to be careful with how your state Medicare reviewer sees your role. Some are very restrictive, others are not. It is a good idea to inquire what policies your local hospitals have regarding APNs. Where I do have privileges, it's so restrictive that it's not worth my time. Although I am also certified as an acute care NP, I cannot gain privileges at some local hospitals because the medical staff has not implemented a mechanism to provide privileges to APNs. There is a "fear" in my area that APNs may take jobs from physicians. Again, check with your local institutions.

I am very busy on the outpatient side. I frequently keep patients from being admitted to hospitals because I often catch problems sooner. In two centers I visit, their CQI measurements improved dramatically once I came on board, which is a direct reflection of my work since the majority of the unit's patients are from our practice. Lastly, check with your area's dialysis unit staff and ask how they would extend privileges to you in seeing patients in their centers. The privileging process can take weeks to months, depending on the facility.

My educational background includes a diploma school degree from Mercer Medical Center in Trenton, NJ (1976); a BSN from Richard Stockton College, Pomona, NJ (1995); completing an MSN-NP Tertiary Program at the University of Pennsylvania, Philadelphia; completing a clinical rotation at Our Lady of Lourdes, Camden, NJ; and gaining certification as a CNN and as an acute care NP (AACN). I have over 20 years nephrology experience in hemodialysis and PD.

Debra Castner, MSN, CNN, NP-C Advanced Practice Nurse Ocean Renal Associates Forked River, NJ

Jean Colaneri, MS, RN, CNN

The APN, whether a clinical nurse specialist (CNS) or a nurse practitioner (NP), needs a masters degree in nursing. This educational preparation is necessary since the APN often deals with patient care issues from a systems and research perspective. My role as a CNS on an inpatient transplant unit requires that I create and manage programs such as patient education and process improvement. For example, when nursing staff noted a high number of skin tears related to tape application in vascular surgery patients, it was my role to provide leadership in resolving this issue through the use of process improvement.

As either a chairperson or committee member, I am expected to participate in multidisciplinary forums that define high quality patient care on clinical pathways and standard orders, and identify and evaluate patient care outcomes in a cost-effective manner. In addition, it is important to stay visible on the nursing unit and approachable to the staff as well as participate in direct patient care. The CNS works with professional nursing staff to develop care plans for complex, seriously ill patients and define expected outcomes. Finally, the CNS works toward the development of an evidence-based nursing practice through participation in nursing research. The CNS scrutinizes all clinical practices with a critical eye as to their relevance in a true evidence-based practice environment.

Jean Colaneri, MS, RN, CNN Clinical Nurse Specialist Transplant/Vascular Surgery Unit Albany Medical Center Hospital Albany, NY

April Zarifian, MSN, RN, CNN

I am a masters educated adult nurse practitioner working for two surgeons in abdominal transplant, (liver, kidney, and pancreas), and general surgery.

My day always starts with scanning the patient list from the computer to see who is in house, and review labs and test results that have been completed in the past 24 hours. I then pre-round with the surgical residents, and then have formal rounds with the surgeon and hepatologist on service.

A typical day will then continue as follows: I started a "hard to stick" IV

and got consent from a patient for a peripherally inserted central catheter (PICC) line, which I did later in the day. After rounds I discharged 2 patients, including writing the orders and prescriptions and finalizing the discharge teaching. I saw 4 patients in the clinic, did 2 work-ups including the pros and cons of the transplantation option, conducted a history and physical, conferred with the social worker, and ordered tests on a diabetic workup to include peripheral and carotid dopplers and an adenosine stress test. After a late lunch in my office, I talked to the referring cardiologist for the discharged patient who had a pericardial window, faxing him inhouse data.

I talked to this month's pediatric nephrologist regarding a pediatric transplant next week, and set up the operating room, HLA (human leukocyte antigen), and admission for patient and donor. I spoke with our educator about the PD workshop to be conducted next month. I usually provide the didactic portion.

I also checked on the CRRT protocol that went out before I left on "vacation," but no one has read it yet (of course I gave them all a reminder). I prepared for and made my afternoon rounds, and finished up individual flow sheets for the day. A new admission arrived so I got her settled in before I went home.

I also touched based with the Parexel study coordinator as to when we will have a drug to start this study. She believes it will be the following week. Thank goodness the sirolimus closeout is next week.

I think that pretty much covers a day in the life of an APN. It is pretty quiet now as we only have 12 inpatients with no fresh transplants -- but that could change at any moment!

April Zarifian, MSN, RN, CNN Advanced Practice Nurse for Abdominal Transplant Tulane Medical Center New Orleans, LA Assistant Editor Nephrology Nursing Journal

Paula Dutka, MSN, RN, CNN

My role as CNS for the Division of Nephrology and Hypertension at Winthrop-University Hospital, a major teaching affiliate on Long Island, NY, has evolved to focus in three functional areas: research, departmental management and education, and special projects coordination. These projects include such tasks as initiation of new dialysis sites, evaluation and initiation of new products/devices, various clinical CQI committees, Y2K readiness, and staff development, just to name a few.

This draws upon the use of advanced education and clinical training to assist with development and implementation of the renal services program at all acute, subacute, and chronic sites, including CVVH in the ICUs. This involves integration of several institutions' policies and procedures, and ensuring regulatory compliance in all areas.

Clinical research coordination is the main focus of my role at this time. This role has grown from the traditional research duties of case report form maintenance and clinical management of patients to also include writing grant proposals and all internal review board correspondence, maintaining all regulatory documents and files, and designing protocol and case report forms.

My ever-changing, evolving role allows for much personal and professional growth and satisfaction.

Paula Dutka, MSN, RN, CNN Clinical Nurse Specialist Winthrop University Hospital -- Dialysis Center Mineola, NY Editorial Board Member Nephrology Nursing Journal

Marithely Morales-Allen, MSN, RN, NP-C

I am an acute care NP working in a private practice with two nephrologists in an urban area. Our office is right next door to the medical center, where the senior partner is the chief of the Department of Nephrology. The group is affiliated with five outpatient dialysis centers, including the dialysis center at the hospital. I am a full-time NP taking care of the dialysis patients' monthly visits at the office. I also speak Spanish, which was a plus considering the large Hispanic population. I also take phone calls from patients and fill out the paperwork (forms needing to be filled, written quarterly care plans, etc.). I also attend monthly rounds with our hospital-based dialysis unit staff (more monthly care plans). I have obtained hospital privileges, which is important when one of the MDs is away and I am seeing patients in the hospital.

As I have discovered, following patients in the hospital is a lot of responsibility. It involves not only seeing patients and writing progress notes, but also talking with case managers, social workers, home care coordinators, dietitians, interns, and residents. I have worked at this particular hospital for about 10 years, and I enjoy it because I feel I make a difference in the care of our patients. When they are discharged, I relay this information to their dialysis units.

Currently, I am tracking trends in patients' labs (PTHs), developed a Zemplar/Calcijex protocol, and trying to develop a peritonitis protocol. "Nephrology Nurse Practitioners in a Collaborative Care Model" (American Journal of Kidney Diseases, Volume 31, Number 5, 1998, pp. 786-793) was used as a basis for my practice.

My educational background includes a BSN from Rutgers University College of Nursing, Newark, NJ, and an MSN in the Critical Care Nurse Practitioner Program at the University of Pennsylvania, Philadelphia. I have also been a CCRN for the past 8 years and I am an ANCC Certified Acute Care Nurse Practitioner.

Marithely Morales-Allen, MSN, RN, NP-C Acute Care Nurse Practitioner Drs. Chenitz & Casella Newark, NJ

Carol White, MN, RN, ANP

I am a new grad adult nurse practitioner. I began working 1 year ago for an 8-physician nephrology practice in Western North Carolina. There is one other NP in the practice who works almost exclusively in the hospital, rounding on patients, doing admission history and physicals, and compiling discharge summaries. I make rounds in the hospital 16 hours a week. Neither of us provide hospital consultations or take calls.

The remainder of my 40-hour work week is spent making rounds in our four dialysis centers, providing episodic patient care, doing H&Ps (primarily preoperative H&Ps for dialysis access surgery), and seeing dialysis patients in the office. I rarely see predialysis patients.

My services are billed for only nondialysis-related problems. I have a Medicare provider number, and if a patient has Medicare and sees me in the office, the patient is billed at 85% of the physician rate. If a patient is seen for a dialysis-related problem, that visit falls under the capitated rate.

I earned my BSN in 1981 and later my masters of nursing degree in 1986 with a major in adult health and a minor in oncology. I worked first in oncology, then in critical care, and ultimately became a transplant coordinator, then CNS for kidney and pancreas transplantation.

In 1996, I went back to school part time for a post-Masters NP certificate. Part of my clinical rotation was in the nephrology practice where I am now employed, however, I had no background whatsoever in dialysis! Consequently, I did more studying after I started this job than while I was in school! I went home from work and studied literally every day for the first 6-8 months of my employment. Quite often I felt inadequate and wished often for more of a dialysis background. Fortunately, the experienced dialysis nurses lent me their expertise and still do! Now I average reading 2-3 journal articles a week. I also make a point of going to as many conferences as I can manage. Fortunately, my employers have been generous with continuing education time.

This job is intensely challenging and rewarding. Most of the time it is just plain "fun." All the nephrologists in this group have been most supportive and are fabulous role models. The most difficult part for me has been coming to terms with the greater degree of morbidity and mortality in this group of patients as compared with the transplant population.

I have also been challenged by the role change from CNS to NP. Although I wish that I had known a nephrology NP to serve as a mentor during my first year out of school, the ANNA Advanced Practice Special Interest Group members who meet on ANNAlink have been most helpful.

Carol White, MN, RN, ANP Adult Nurse Practitioner Mountain Kidney Associates Asheville, NC

Deborah Miller, MSN, RN, CNN

I am a CNS in pediatric nephrology in a not-for-profit hospital. My masters is in long-term care nursing, a good fit since I work with patients for many years, often their entire childhood. My clinical rotations were spent in a lupus clinic in an adult nephrology setting and in pediatric home care/case management.

In the outpatient setting, I oversee the home PD program and do the family teaching. Case management of chronic, complex patients takes a good portion of my time. Our PD census varies from 12 to 24 patients, and as clinical specialist I make changes to the dialysis prescription and medications that are on protocol (such as EPO and iron). In the state of Virginia, a CNS does not have prescriptive privileges. I spend a large proportion of time with newly diagnosed renal failure patients and mothers of babies with chronic renal insufficiency, primarily teaching and encouraging. This role is as a member of a team, including the physician, social worker, and dietitian.

I have responsibility for cost control of the home PD program and departmental QI. I am also responsible for all reporting to the network and the pediatric registry (NAPRTCS). I wrote the training manual for home PD and am responsible for maintaining our readiness for inspection by the state or the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).

This small department has 3 pediatric nephrologists, a receptionist, a nephrology nurse, and myself. With only 2 nurses, we share call for the dialysis program giving plenty of opportunity for hands-on nursing. This includes acute hemodialysis, acute PD, and initiating and troubleshooting hemofiltration. It also includes evaluating patients for suspected peritonitis and initiating treatment according to protocol. I am responsible for the readiness of these acute programs. Staff development is included in my responsibilities along with the study coordinator role for any research projects.

The role is challenging and diversified enough to keep me from getting bored. I work with excellent physicians who give me a great deal of leeway in managing the patients and the programs. The extra hours from call are getting more difficult physically and emotionally and I would gladly relinquish them. However, the challenges, the support, and the variety lend itself to enormous job satisfaction.

Deborah Miller, MSN, RN, CNN CNS Pediatric Nephrology Inova Fairfax Hospital for Children Falls Church, VA
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Author:Child, Sherry L.; Easom, Andrea K.; Castner, Debra; Colaneri, Jean; Zarifian, April; Dutka, Paula; M
Publication:Nephrology Nursing Journal
Geographic Code:1USA
Date:Apr 1, 2000
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