Embracing the Role of Advanced Trained Nurses: Walking the Walk of Team

The New York Times published an article recently about the increasing trend of nurses getting advanced degrees. “[In 2010] 153 nursing schools gave doctor of nursing practice degrees to 7,037 nurses, compared with four schools that gave the degrees to 170 nurses in 2004, when the association of nursing schools voted to embrace the new degree. In 2008, there were 375,794 nurses with master’s degrees and 28,369 with doctorates.”(1)   The concerns expressed by a variety of groups in organized medicine was over the use of the title “doctor” for the nurses who had earned a PhD, with possible confusion of patients over who was a “real” doctor. Clearly this is a smokescreen and the real concern is over control and concern over the slow “intrusion” of nurses into medical practice. This concern is curious since it is clear that there continues to be a significant workforce deficit in primary care and in medical subspecialties such as nephrology.

Recent data from the Renal Physicians Association confirms what all practicing nephrologists already know: The patient population with ESRD and CKD is growing and is increasingly medically complex; the ability to recruit new nephrologists into practices is decreasing, with stagnant training programs and large numbers of IMGs not remaining in practice in the U.S. following training; there is increasing demand on time for administrative activities, including fulfilling the requirements of the Conditions for Coverage to carry out Medical Director activities appropriately; continued pressure from hospitals and other organized care systems to become salaried physicians; and constant downward pressure on reimbursement for physician services. All in all, working harder for less. It is time we applied the age-old adage, work smarter, not harder, and embraced ways of doing this, like working in teams and expanding the use of our advanced nurse colleagues.

There is no area in medicine where the interdisciplinary team (IDT) is as critical to optimizing clinical outcomes as it is in ESRD. Most people, however, narrowly define the IDT as the physician and various teammates in the facility (nurse, technician, dietitian and social worker). This narrow paradigm is critical for driving outcomes, as we showed in a recent publication. (2) When we looked at process measures that significantly correlated with survival at a facility level, IDT meetings were critical, particularly following sentinel events like hospitalizations. That is fine as far as it goes, but it is now apparent that this is necessary, but not sufficient to get the best outcomes.

Focusing on the holistic needs of the ESRD patient is essential, as demonstrated in the recently completed CMS ESRD Demonstration project.(3)  Attention to preventative care, including immunizations, control of diabetes, fluid overload and aggressive medication management all lead to better overall outcomes. But who is going to relentless pursue these things? The nephrologist?  The dialysis facility core team? We need to expand the definition of the IDT to include additional members, such as advanced practice nurses who cannot replace the nephrologist, but can enhance the team by addressing these key areas of care. If we do, we will truly be walking the walk of team, and our patients will be far better off— withbetter clinical outcomes and higher satisfaction with their care.

If we as nephrologists are to fulfill our responsibilities as leaders of dialysis facilities and clinical care for our vulnerable patients we should remember what the organizations guru Peter Drucker said:

“The leaders who work most effectively, it seems to me, never say ‘I.’ And that’s not because they have trained themselves not to say ‘I.’ They don’t think ‘I.’ They think ‘we’; they think ‘team.’ They understand their job to be to make the team function. They accept responsibility and don’t sidestep it, but ‘we’ gets the credit…. This is what creates trust, what enables you to get the task done.”

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

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