Skilled Support for Patients and Practices

Working in Atlanta’s inner-city Grady Hospital, Carlone’s duties are in constant flux. Credentialed by the hospital as a provider, she can also “jump in and see patients,” she notes. Dwindling budgets result in “little social work support,” she says, so on a recent afternoon she was helping a functionally illiterate patient to fill out forms. Connection to her low-income patient population has led to her launching a health literacy study. She has also, since her first attendance at an ACR/ARHP meeting in 1999 (when she joined the rheumatology division at Emory University), been active on the annual meeting planning committee and works to educate other departments and specialties about appropriate referral to the rheumatology service.

Double Learning Curve

Rheumatology has become an outpatient specialty, so exposure to rheumatology during registered nurses’ largely hospital-based training is often minimal. NP training is usually primary-or acute-care based, with limited exposure to rheumatology specific practice. Most of the NPs with whom we spoke acquired their rheumatology training on the job, receiving didactic training from supervising physicians, just as fellows do. Attending the ACR/ARHP Annual Scientific Meetings, taking premeeting courses, and pursuing additional readings all add to their knowledge base. Huisinga was well supported, she says, by the VA in her educational efforts.

During the recent meeting of the ACR’s Pediatric Rheumatology Symposium, Karen Kerr and Dr. Lasky facilitated roundtable discussions regarding the incorporation of NPs and PAs into rheumatology practices. “I think most rheumatologists and rheumatology NPs would agree that a new NP without prior training in rheumatology would need between six months and a year to acquire the competency and skills for seeing patients independently,” reported Kerr.

But acquiring expertise in rheumatology comprises only learning curve number one.

NPs—and their practices—may also go through a second learning curve if the physician has never worked with an NP before. Rizzo, who was hired as part of a research grant in 1996 by her group practice, says that “everything was new” to the physicians as well. The first year or so consisted of a “give-and-take” process she says. “They wanted to see what I could do, and I wanted to see how much independence I could earn.” The year and a half grant period gave her time to prove that she could be a revenue generator and could collaboratively manage patients. NPs can diagnose and treat patients independently; however, in a subspecialty such as rheumatology, NPs may collaborate with physicians on a more regular basis. “I would never think of myself as a rheumatologist,” says Rizzo. “Quite often, I verify things with the rheumatologist, just to be sure I’m on the right track.”

Scope of Practice

NPs follow a different educational course from PAs. Typically, they must be a graduate with a master’s degree or higher, and complete NP requirements while holding an active and unrestricted registered-nurse license. Many states require NPs to pass a certifying test administered by the American Nurses Credentialing Center, the American Academy of Nurse Practitioners, the Pediatric Nursing Certification Board, or the National Certification Corporation. There are multiple designations and certifications depending on the level of education completed by the NP. A new advanced-practice registered-nurse regulatory model has been proposed by the National Council of State Boards of Nursing and the American Association of Colleges of Nurses that will require, by 2015 that the entry level for all NPs will be a doctorate degree. (For more information, go to www.ncsbn.org/aprn.htm.)