Lessons Learned: Reflections of a Cardiovascular Nurse
Team-Based Care | I read with interest the recent 2015 ACC Health Policy Statement on Cardiovascular Team-Based Care and the Role of Advanced Practice Providers1, notably chaired by a physician and an advanced practice nurse, and co-authored by a team that represents the disciplines of medicine, nursing, pharmacy and physicians assistants. I extend my congratulations to the writing team and to the college for its work over the past 12 years in welcoming registered nurses (RNs), advanced practice nurses (APNs), pharmacists, and physician assistants (PAs) as members of the ACC! As an APN who was among the first to become an ACC member in 2003 and participate actively in committee work, this document is a welcome addition to the library of health policy statements. Reflecting on the past 12 years, there has clearly been an evolution in the depth of the incorporation of non-physician professionals as ACC members. Those of us who have been part of this journey have also learned some important lessons.
Each profession has its own distinct culture. Retaining that culture allows the team to leverage the respective strengths of each to develop a superior clinical team. All of us involved in organizational changes like this need a measure of cultural competence to navigate these new interdisciplinary relationships. Since the ACC first welcomed RNs, APNs, PAs, and pharmacists as ACC members, all of the stakeholders have grown in awareness of the culture of the other disciplines. Initially, the College, in an effort to choose an appropriate term to describe the new non-physician members, created the membership category “cardiac care associates.” The term has since been replaced by cardiovascular team (CVT) section. Nurses, PAs, and pharmacists have a large measure of professional pride in their respective professional groups, and greatly value their association to their profession, their education, professional designation, and licensure. Most were not fans of the term “cardiac care associate,” a well-intentioned but unfortunate term created to describe the new non-physician membership category (in much the same way that most of APNs cringe at the term “mid-level” or “physician extender”2). None of these terms was coined to be pejorative, but like any group with a strong culture and identity, terms do matter to us, and names are not inconsequential.
When the ACC initially welcomed nurses as members, it was required that applicants for membership be recommended by a physician colleague. While this was consistent with requirement for physicians seeking ACC membership also, the requirement alienated some would-be ACC nurse members. Nurses were not accustomed to requiring a sponsor to become a member of a professional organization. A recommendation by a current ACC member is still required for nurses applying for membership, but a recommendation letter can now come from another CVT member. I believe this inclusive change has served to help grow the nursing membership.
Concurrently, I believe that CVT members have grown in respect for the tradition and history of the ACC. A membership of 4,600 CVS members is impressive; however, this is part of an overall ACC membership numbering nearly 50,000! The ACC is a 65-year-old organization with a deep and proud history whose identity has changed by the altered complexion of its membership over these past 12 years. Membership-wide acceptance of the inclusiveness we have enjoyed does not happen overnight. But now, in 2015, nurses, APNs, PAs and pharmacists are an active part of many/most committees, councils and writing groups. Those of us who have been active participants and leaders in the college have cultivated alliances and invested in relationships with physician colleagues that have helped us to participate and also to lead effectively and credibly. This mutual respect between and among professions is a key component of cultural competence.
Professional Direction and Mentorship from Our Own
Each profession needs to direct its own practice, govern itself, and mentor junior professionals.
APNs, RNs, and PAs appropriately look to their physician colleagues for their clinical expertise in a collaborative practice setting. It is important, however, that we remember to seek the counsel of mentors and senior leaders in our own respective professions for career advice, leadership, scope of practice issues and overall direction. Those of us in more senior career stages need to take “to heart” our responsibility as mentors to emerging leaders by modeling a collaborative and collegial interface with all team members. Importantly, in order that our profession remains competitive in recruiting and retaining promising future cardiovascular nursing leaders, we need to be attentive to the four key messages of the Institute of Medicine’s Future of Nursing3:
- Nurses should practice to the full extent of their education and training.
- Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
- Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States.
- Effective workforce planning and policy making require better data collection and an improved information infrastructure.
Likewise, APNs, RNs, PAs, and pharmacists need to look to their professional organizations for advocacy issues important to their own unique professions. Active cardiovascular clinical professionals should join, or, at minimum, engage with, their own professional societies to engage in advocacy issues that impact the nursing profession. The American Nurses Association (ANA) and the American Association of Nurse Practitioners (AANP) represent the interests of nurses and nurse practitioners respectively. Additionally, cardiovascular subspecialty nursing organizations like The American Association of Heart Failure Nurses (AAHFN), the Society for Vascular Nursing (SVN), and the Preventive Cardiovascular Nurses Association (PCNA) add value with in-place and virtual and on-demand continuing education opportunities and patient education tools. Each of these organizations brings important value that nurses in subspecialty cardiovascular practice settings can leverage to enhance their clinical practices.
Additionally, involvement in the American Heart Association (AHA) can add an additional dimension in terms of both national and local volunteerism and advocacy in the public health domain.
The ACC took an important leadership position when, in 2008, the college worked with the ANA to convene a group of nursing leaders to publish Cardiovascular Nursing: Scope and Standards of Practice.4 This was a very important step in the development of collegial relationship with cardiovascular nursing organizations, one that helped to form a strong basis for ongoing liaison relationships that have helped to strengthen professional education efforts. We admittedly are all in competition for the same members, but we have been able to identify numerous opportunities for collaboration-opportunities that have strengthened and added value to our individual efforts—and have certainly impacted the quality of cardiovascular care.
It Takes a Village
The demands of our current system are increasing every year. We need increased resources for interactions with third party payers, registries, data warehouses, and others to assure coordination of care between and among providers and systems. We have important roles in coaching patient to improve self-care management and adherence. To accomplish all that is required of us during the always too-short acute care stay or ambulatory clinical encounter, we need to leverage all members of the team. The ACC has gathered the key stakeholders, but there are others we need to incorporate into the team to satisfy the six aims of high quality care-care that should be safe, effective, patient-centered, timely, efficient and equitable.5
In patient-centered medical home (PCMH)6 practice redesign tactics, the team includes not only physicians, pharmacists, PAs, APRNs, and RNs, but it includes support staff as well. For example, front desk scheduling staff can encourage patients to arrive for their visits armed with pertinent documents like home blood pressure records and questions for the clinician and can direct them in accessing important community resources as needed. The medical assistant who “rooms” the patient can support self-care management by reinforcing health messages and encouraging the patient and his/her care partner to have questions and concerns ready to discuss with the clinician. All of these team members can increase the likelihood that clinical professionals will utilize their time with the patient in a practice that takes full advantage of their knowledge and training-working to the limit of their licensure. In our metrics-focused environment, we also need to increasingly leverage the talents of our non-clinical professional colleagues from the engineering world who design, analyze, and measure a complex system in order to improve its safety, timeliness, efficiency and effectiveness.7 These are the professionals who, with our clinical input, create systems that make “the right thing to do the easy thing to do.”
In the End, It’s Not All About Us
All cardiovascular clinicians are struggling with professional practice issues today. We are overwhelmed with the amount of time and work that documentation requires, and the work of scrupulous medication reconciliation. Physicians struggle with maintenance of certification and declining reimbursement. APRNs struggle with state to state variation in scope of practice issues. Many RNs are returning for school for additional education at the masters’ level to attain a higher level of job security. Strategies that increase patient centeredness, engagement, and involvement in self-care are all great concepts, but they demand learning new ways of thinking and doing; they require more of the scarcest commodity we have today: our time. But for all of the issues facing our professional groups individually and collectively, in the end, it’s not about championing or advocating for our individual professional groups. It’s really all about improving outcomes for the most important member of the health care team: the patient.
Article written by Suzanne Hughes, MSN, RN, who is Chief Learning Officer at the Preventive Cardiovascular Nurses Association.
- Brush JE, Handberg EM, Biga C, et al. J Am Coll Cardiol. 2015;65:2118–36.
- Hoyt KS, Proehl. Advanced Emergency Nursing Journal. Vol. 34, No. 2, pp. 93–94.
- IOM (Institute of Medicine). 2011. The Future of Nursing: Leading Change, Advancing Health. (Washington, DC: The National Academies Press.)
- Cardiovascular Nursing: Scope and Standards of Practice. 2008. American Nurses Association and American College of Cardiology Foundation.
- Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century, (Washington, D.C.: National Academies Press, 2001).
- Wagner, E.H., Coleman, K., Reid, R.J. et al. (2012). Guiding Transformation: How Medical Practices Can Become Patient-Centered Medical Homes. The Commonwealth Fund.
- President’s Council of Advisors on Science and Technology (U.S.). Report to the President, Better Health Care and Lower Costs: Accelerating Improvement Through Systems Engineering. [Washington, District of Columbia]: Executive Office of the President, President’s Council of Advisors on Science and Technology, 2014.
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