Jennifer M. Sharp, MS
University of Michigan
When I began my advanced practice career, nurse practitioners (NPs) had been around for some time. The first nurse practitioner program was developed at the University of Colorado in 1965 by Loretta Ford and Dr. Henry Silver. The program was focused on pediatrics, and historically, most NPs were employed in primary care specialties. NPs were able to add to the provider work force in physician offices, increasing the number of patients able to be seen and followed by any given practice. Over time NPs began to develop individual niches and opened independent clinics with the supervision of a physician. The role evolved further as the industry was able to see that both physician assistants and NPs, now collectively termed Advanced Practice Providers (APPs), were able to expand care capabilities in more focused areas of medicine, such as acute care, surgery and critical care. Nurse practitioner schools began to develop acute care programs and other specialized programs for broadening the scope of APPs into hospital settings and subspecialty practices. Regulations were developed to better define the role of APPs and to take on issues of training and certification that naturally coincided with this expansion of APP practice environments.
While the addition of APPs to the medical workforce was a positive change for health care in general, there were a lot of murky waters to tread. While many physicians were on board with this expanding venture, others were unsure and unclear as to what APPs were supposed to be doing. What can they do? What are the liabilities? What is the difference between nurse practitioners and physician assistants? What is their scope of practice? How do they fit in on our team? What is the benefit of working with an APP? The uncertainty of answers to these questions led to confusion that likely contributed to underutilized APPs, decreased job satisfaction, and confused employers and team members.
My Center, My Story
I started in transplant as a bedside nurse, first at the Johns Hopkins Hospital (JHH), then at University of Michigan Health System (UMHS). After completing my training as a nurse practitioner, I transitioned to transplant surgery. I emailed Dr. Jeffrey Punch, then the Chief of the Division of Transplant Surgery and the director of the UMHS Transplant Center, more than once. I even encountered his wife (also a physician leader at UMHS) in an elevator, at which time I promptly explained who I was and why her husband needed to hire me. The possibility of working as a NP in the transplant program was a very unique opportunity. It was a natural evolution for me but somewhat confusing for those around me. I was a little bit like a transplant unicorn. I had lots of bedside nursing experience with the transplant population, which was hard to find at the time, but I was now a mid-level provider (which was what we used to be called) able to use that knowledge and experience in a more in-depth manner on the transplant team. The team did not have an inpatient nurse practitioner. Dr. Punch probably thought: “This woman has emailed me repeatedly and confronted my wife in the elevator; maybe I should hire her. She seems persistent. But what do I do with her? What’s an acute care nurse practitioner? How do we train her? Do we let the existing PAs train her?” These were legitimate questions plaguing program directors who were hiring APPs at the time. In our program, I worked alongside my fellow “MLPs” and learned the job. There were 4 of us (3 PAs and me) working with the inpatient team coordinating discharges and other tasks. We also completed H&Ps for kidney patients and saw post-operative liver transplant patients in clinic two days a week. Our center volume was 250 kidneys and 90 livers a year in the abdominal transplant programs at that time.
Fast forward to 2018: our transplant surgery team at Michigan Medicine is now 7 APPs (2 PAs and 5 NPs). We function in the outpatient and inpatient setting alike. Collectively and via self-management, we take day call for the inpatient kidney service, oversee the junior residents who take day call for the inpatient liver service, cover 3-4 clinics each day for post-operative kidney/pancreas and liver patients, and see all pre-operative living donor kidney and liver patients prior to surgery. We are making clinical judgments and providing care in the acute setting as well as directing and following through with plans of care in the outpatient arena. We run daily multidisciplinary rounds and collaborate independently with all departments. We act on behalf of our faculty in matters of patient care when they are not available. Our role in coordinating care for the post-operative liver transplant patients has been studied and shown to improve care coordination and contribute to decreased length of stay.
In addition to patient care, we serve on transplant center and hospital committees. We have been able to grow our group and retain talented providers. We collaborate with faculty on best practices regularly. We are involved in research, attending and speaking at national conferences. Additionally, some of us have been able to independently develop significant quality improvement interventions that have been implemented for the benefit of patients. We participate fully in the education and training of surgical residents, medical students, and NP students both in inpatient and outpatient care settings. We also play a critical role in orienting the ASTS transplant surgery fellows to our program each year.
How and Why Did This Happen?
The answer to these questions is complex. We know our patients have become older and sicker. Their needs have grown. Their time waiting for organ transplantation has increased. The manpower needed to manage these patients is increasing. In addition, the Accreditation Council for Graduate Medical Education work hour restrictions instituted in July 2011 have limited the amount of time residents spend in the hospital caring for patients. These issues combined have created a growing need for additional providers to meet the needs of the transplant patient population. Responsibilities have grown to meet the needs of patients, including daily clinic expansion, increasingly complex outpatient management, and maintaining the necessary continuity for successful patient outcomes and patient safety. The role of the APP has evolved in that we are able to manage, and we have gained a more autonomous role in directing, the care of transplant patients in both inpatient and outpatient settings. We provide an aspect of care continuity that is unique and have grown into a large, invaluable part of the transplant team to our faculty, fellows and patients.
Is This Model Successful?
For our center, this model is successful. All seven of us are able to fill in at any time, in any of the areas of responsibility. This is particularly important in transplant, as the daily work volume is unpredictable and highly variable. We continue to review and revise the role as the needs of our patients demand.
We have been successful in providing care and education by combining the following:
- Relationships: Getting to know and trust one another; understand preferences, values, and the things that are important to each other; respect each other inside and outside of the office.
- Time: It has taken years to cultivate these relationships. We have successes and failures, missteps and saves, and go through all of it together, growing professionally and personally, as a cohesive team.
- Common mission/teamwork: We depend on each other to get to our common goal: excellent, timely, and safe delivery of care to our patients. We all need one another to provide the standard of care we believe in from beginning to end of the patient experience.
These factors are not often studied or written about. But there is a common thread among transplant teams that provide exceptional care: they work well together. Each member understands that an individual cannot carry out our mission alone. The care we provide is based around the team and the systems in which we operate. APPs enhance this structure of care delivery at Michigan Medicine.
What Is Next for the Advanced Transplant Provider (ATP)?
I have described the role of the surgery APP group at Michigan Medicine. However, there are APPs all over the transplant center in every division. The field of transplantation is made up of several teams: medical, surgical, pre, post, and everything in between. APPs on all these teams form another layer of connection. We provide the same underlying network for all the specific organ teams, performing different responsibilities but overall ensuring that all patients have what they need, continuously.
Nationwide, APPs can be found in different transplant programs in clinic, in the hospital, in outreach, assisting in the operating room, and on procurements—each with different responsibilities in kidney, liver, pancreas, lung, heart, and small bowel organ transplantation. APPs are known to complete morning rounds, write progress notes, perform H&Ps, perform pre-transplant evaluations, oversee waitlist management, participate in transplant protocol development and quality improvement activities, manage post-transplant clinic follow up, coordinate discharge, and take in house and at home call. Currently there are several NP/PA fellowship programs around the nation that developed to intensify and specialize training that is needed in relation to the growing industry as APPs take on more responsibilities in transplant centers around the country and in other areas of health care.
It is my perspective that the next logical step for the transplant advanced practice provider is to be placed into a dual role, both clinical and administrative. We have proven how versatile we are in our current clinical position. Transplant centers can only benefit from positioning APPs in leadership roles that develop center policy, mission goals, center operational strategies, fiscal development, competitive practices, and center organization.
Being an ATP has afforded me a vast array of opportunities to grow in my profession. Transplant is a complex field. It has many moving parts. There are many important aspects of care that require extra attention and time. It is clear that the ATP role in transplant centers in today’s healthcare delivery environment is now indispensable. I have heard our role described as many things through the years, some accurate and some not so accurate. The real deal is that it is hard to define this role universally. It is all relative to where you work, what the needs are, and what structural model is utilized at that particular center.
The field of transplant is very well suited for the APP role. The patients require intuitive, highly skilled, and continuous care. The APP allows the team providing this care to be just that: continuous. When working in tandem with faculty, the role allows for minimal breaks in delivery of quality patient care. I have no doubt that this role will continue to evolve in all parts of healthcare.
Having said that, the role of an ATP is specific to institution; efforts are still being made for standardization in skill sets, responsibilities, and scope of practice. There are advantages to creating a value-added role from the ground up in a particular patient population at a specific center. However, developing standard responsibilities that can be maintained by the ASTS could certainly be a helpful tool for employers and personnel alike in the ever-changing health care environment.
In an effort to continue the discussion on this topic, the Communications Committee will be collaborating with the ATP Committee members in coming months to collect job descriptions from ATPs around the country. There are currently 93 ATPs within the ASTS membership. This collaboration will give more insight into the diversity in structural models and current roles throughout the field of transplant. There is every reason to expect that ATPs will continue to play a growing role in the field of transplantation, and the ASTS is poised to help lead that growth.