Transcription:
Advancing Advanced Practice Nursing

Trisha Williams: Hi, guys. Welcome to the third season of the Advanced Practice Perspectives. I'm Trisha Williams.

Tobie O'Brien: And I'm Tobie O'Brien. This is a podcast created by advanced practice providers for advanced practice providers. Our goal is to provide you with education and inspiration. As you all know, we typically chat with pediatric experts, and we also typically interview advanced practice providers at Children's Mercy. But today, we are stepping outside of those lines and we are doing something a little bit different and we are super excited.

Trisha Williams: We are. We're kind of changing things up here on the podcast, and I am so stoked about today's episode. So before I introduce our first guest, let me give you guys a little bit of a background.

So a few months ago, Tobie and I had the pleasure of presenting our podcast at a national conference. It was a National Magnet Conference. So, Magnet is a recognition that hospitals get for excellence in nursing, and we were there. And during our presentation, we extended an invitation to the advanced practice providers in our group to be on our podcast. We wanted to know what they do for their job and what their expertise are, and kind of what they would want to share on our podcast. And so, we had some amazing applicants across the country from Maryland all the way to California. So coast to coast, we had people that wanted to be on our podcast.

And Tobie and I and our Director of Professional Development sat down, and we decided that Megan Atashroo is going to be our guest today on our podcast. So, she is a family nurse practitioner and also the Director of Advanced Practice for the Cardiovascular Health at Stanford Healthcare. So welcome, Megan, to the podcast. We're so excited.

Megan Atashroo: Thank you for having me. I'm really excited to be here as well.

Trisha Williams: We are so excited. So, tell us a little bit about yourself so that the listeners know who you are.

Megan Atashroo: Yeah. So, I am actually from the Midwest, so it's really nice to be talking to both of you because I know exactly what Children's Mercy is and familiar with Kansas City. So, I grew up in St. Louis. And I went to college at the University of Missouri there in Columbia.

And I went to Mizzou for my undergraduate nursing degree, and then I also stayed there to get my master's degree as a family nurse practitioner. And then after graduating, that's where I met my husband, who also went to Mizzou. He went to Mizzou med school. And so then, we were following him around as he was on his residency training track, and his position brought us out to California almost a decade ago. So now, I've been away from the Midwest for quite some time. And we always knew we wanted to live out west because we love the mountains and the outdoors, but we thought Colorado, because that's close to Kansas City. You can still drive home and see mom and dad. But ended up out here in California and really loved it.

And so, that move for me was happening around the same time that I was graduating with my nurse practitioner degree and was fortunate to get my first position as a nurse practitioner at Stanford Healthcare. And so, I've basically spent my whole nurse practitioner career working at Stanford in the cardiovascular health space. So, I started as a new grad nurse practitioner in the specialty of cardiac surgery, which aligned with what I was doing as a bedside nurse. I was a bedside nurse at University of Missouri Hospital in the CVICU and really loved that patient population. And so, it was a natural transition to just move into the provider world and take care of a similar patient population.

And then from there, I've continued to work in that specialty. I still see patients today, although my role is a lot more heavily management and administration, but held a few different positions over my tenure here at Stanford, including lead advanced practice provider, so managing a small group of advanced practice providers that were working on a team. I had the opportunity to develop a CT surgery APP fellowship program, and served as clinical coordinator for that, which was really awesome. It's probably my favorite job I've ever had. And then most recently, I've been in the director position for the last three years.

So, we're here to stay in California. I love working at Stanford. We get back to the Midwest about once a year, which we usually come over 4th of July because Missouri knows how to do it for the 4th of July. In California, you can't set up fireworks, like the state will set on fire. So, I like to bring my family back and my kids back and show them a real proper summer.

Tobie O'Brien: Oh, I love it. That's true. We sure do know how to set off some fireworks for like a week at a time. Like, a whole week long is dedicated to it.

Megan Atashroo: Yeah, I'm sorry I come back and add to that.

Tobie O'Brien: No. Well, we are so glad that you're joining us. And what a story. It's great. It was really great to meet you when we got to meet you a few months ago and hear your story or read your story initially and then get to hear it from you today. So, we are so glad that you are here.

I did want to kind of circle back to talk a little bit about Magnet and kind of what we were all doing out there. I actually didn't know a ton about Magnet. Well, maybe about five years ago, I learned a little bit more about it. But as Trisha had mentioned, Magnet is a recognition program for the hospitals and it heavily just makes sure that the nurses are getting the education really that they need and the support that they need to be the best nurses that they can be, that also applies to advanced practice nurses. And so, that is where the three of us had met. And so, there were not quite as many programs dedicated to the advanced practice side of things at Magnet, but there were a few. And so, a lot of them were focused on this fellowship or consideration of a fellowship program idea. And that was kind of a talk amongst many of us.

I was really hoping we could talk about how you recognized a need for the CT surgery APP fellowship program and tell us about the steps that it took for you to create the subspecialty fellowship program.

Megan Atashroo: Yeah. So, going back to when I started as a new grad in cardiac surgery at Stanford Healthcare, this is 2014, this was also aligned with a time when the department had a new incoming chair. And the chair was coming from the East coast and was really familiar with working with advanced practice providers and wanted to bring that model to our institution. And so, very quickly there was this really quick ramp up of, okay, really the strategy was the surgeons are going to focus on operating, and then we're going to hire advanced practice providers who are going to become experts in all of these different areas, so support the preoperative process, first assist in the operating room and then provide that inpatient postoperative care because most cardiac surgery patients have about a five to seven-day hospital stay after their surgery.

And so, the department was growing and we were hiring advanced practice providers really quickly. So when I started in 2014, there were only five of us working in the specialty. And as I talked to you today, there's 60. And that happened in the span of maybe five years that we did this really quick ramp up.

And so, as we were getting approval from a business perspective, like, "Yes, the business plan makes sense and here's approval for the requisitions and go find people to come and work and do this type of job." And what we noticed in the candidate pool was that there was a lack of specialty-trained APPs, which is like by design. Because I think, as advanced practice providers, we're generally trained. And then, we're sort of like stem cells. You can sort of like become any different type of specialty with the right support and the right training. So, we definitely saw that in our candidate pool. Most of our applicants had less than a year of experience at all as providers. So, there's lots of new grads out there looking for jobs. I was taking a long time to recruit people. And then at the same time, we were experiencing a little bit higher turnover and vacancy rate in some of our established positions.

And then looking ahead, we were anticipating that we were going to continue to grow. And so, one of our solutions to try to support filling all of these positions and really creating this robust expert advanced practice team in the specialty was to develop an advanced practice provider fellowship program in the specialty of cardiac surgery. And I was in a position where I had started floating between a few of our different subspecialty groups at Stanford, so some cardiac surgery. Advanced practice providers are what I would call like full scope. So, they're sort of doing everything. Like they go to the preoperative clinic, they scrub the cases and they also do the postoperative care. That's more similar at like a community-type hospital. Where I'm working, at Stanford Healthcare, patients are more complex, more acute. And so, we've actually needed to divide ourselves into even like subspecialty teams. So, we have groups of advanced practice providers that focus specifically on that preoperative workup or specifically on critical care, or specifically on working in the step-down unit.

And so, back many years ago, I had started floating between those three different teams. Just given my background as a bedside nurse, I was suited to go to a few different areas and saw how it would all fit together and how we could create a nice curriculum where applicants or the fellow could go through in a year and be exposed to the full experience that the patient has and then really set them to work in one of these areas, but they would have the big perspective of how it all fits together.

And I was really fortunate that I didn't have to recreate the wheel. So, what we did was a specialty area collaboration with a larger institution. So at Stanford, we do have a Center for Advanced Practice. And there was a fellowship that already existed and another specialty in cancer care. And so, it was a collaboration between the cardiac surgery service line and the Center for Advanced Practice to build off of what they had already done, because they'd already had a pretty successful program and had learned a lot through their experience of developing a fellowship program, but then sort of tweaking it and giving it the specialty flavor and the nuances that these fellows would need to know to be successful in this specialty.

So, 2019 was when we accepted our first cohort. So, we've now graduated four cohorts of fellows from our programs. We have the fifth cohort here right now. And, yeah, it's been a really great program. I think when we developed the fellowship, really we had three goals in mind as to what we wanted to achieve. The first was we did want to support new graduate APPs as they transitioned to practice. So, learning how to be the provider and step into that provider role, especially while our nursing background is an asset, it can also be difficult to make that transition from being the person who is doing the assessment and gathering the information to now synthesizing all of that together and making a diagnosis and developing a treatment plan, and then following up on that treatment plan and really being in charge of the care of the patient. So, we wanted to make sure that we had a way to support this large pool of new graduates that we saw applying to our positions, but support them as they transition to becoming providers for the first time.

The second goal was to provide a broad foundation of specialty knowledge and skills. So like I sort of alluded to the fellows, the way our fellowship is structured now in cardiac surgery, they rotate through all of these different subspecialty areas. So at the end of the fellowship, they aren't necessarily an expert in critical care or in the operating room, but they've been exposed to the full complement of the areas that a cardiac surgery patient would spend time. And they've developed some specialty knowledge that we've outlined in alignment with national guidelines for the specialty.

So with those two things in mind, I mean, we've obviously enjoyed the program because we've continued it for five years now. And some of the benefits are having an avenue or a platform for new graduates. So now, we are able to accept new graduates into our program and we feel really confident that we have a great way to train them to the specialty, and many of them stay at our organization. All of them stay within the specialty. Some of them have gone out to work at other institutions, which is also a benefit as well, but many of them stay at our institution. And what I've noticed is that at the end of one year, so they're really only one year into practice, but they almost function like an advanced practice provider who's been working more like three to five years. So, they really do learn a lot and progress pretty quickly into really embracing the role of a provider during this fellowship program.

And then, one of the other like unintended consequences or something that we didn't anticipate was the professional satisfaction that the preceptors and all of the individuals that participated in training the fellows were going to experience and how that would actually help our retention of more experienced staff. So, the way that we have our fellowship program structured is there's a fellowship director who oversees the structure of the specialty programs, and then there's a specialty coordinator within each specialty who really does the day-to-day coordination, the coaching, the mentoring, and the teaching. But then, we rely on the program is impossible without really, really good preceptors that we establish in all of these different areas where the fellow's going to rotate. And that preceptor takes on the joy and the burden of teaching a new graduate how to function as a provider and all of those clinical nuances that they need to know. And then, this like team of 60 advanced practice providers that we have also help facilitate the didactic component of the training. So, the fellows spend the majority of their time patient-facing doing clinical rotations, but they do have dedicated didactic time every week where they're listening to lectures from our advanced practice providers or from other care team members, and they work on a special project for the year. We have a goal that all of them submit an abstract by the end of the year. So, they get some of that professionalism as well sort of ingrained in the fellowship year.

So, the program has been really successful. And now in my position where I oversee cardiac surgery, vascular surgery, and cardiology, I'm so pleased that we've expanded our fellowship program and we now have a fellowship program available in the specialty of electrophysiology. So similar story, an even more niche specialty, but an area where APPs can be highly utilized. My team of electrophysiology advanced practice providers follow their own panel of patients independently. They manage their pacemaker devices that they have, manage anticoagulation and complex arrhythmias. And we wanted to expand that. But it was same thing, it was taking almost a year to train people to the specialty. It was hard to find people who had any experience in this specialty. And so, we launched what we think is the first in the nation, or actually, I think I might be able to say first in the world, APP fellowship program in electrophysiology last year and have graduated one cohort and we're in our second cohort right now.

So, it's been really great I think to see these APP fellowship programs develop and provide a path for individuals that really want that specialty training. And then also, you get such great support as you make this huge transition to becoming a provider.

Trisha Williams: I have so many thoughts running through my head right now about this program. So where Tobie and I work, we work in a subspecialty field at Children's Mercy. And we have a fellowship program, but it's an overarching umbrella, like general fellowship program. And they have different projects that they do, but there is nothing that is subspecialty-based. So, the fact that you have this incorporated subspecialty-based fellowship I think is so important. Because you're right, when we graduate from grad school, I loved what you said about we're stem cells, we can be morphed into anything to take care of the different population of patients that we want to serve, but we have to have that knowledge base. And so, I'm in awe of you about setting up this subspecialty fellowship program.

So, one of the questions that I have is,

Do you feel like having the subspecialty fellowship program, one, adds more credibility to advanced practice providers working in subspecialty roles? And two, do you feel like that it allows the general public and our physician colleagues to see us more knowledgeable and to add more value to the subspecialty?

Megan Atashroo: Yeah. Great question. So, I'm thinking back to when the fellowship was still just in theory. It was something that we wanted to do. And one of the things that was really important as we were planning and going to ask the organization for funding for the physicians was to make sure that we had buy-in from the key stakeholders at our organization. So, physicians are certainly a big part of that. So, identifying a physician champion for our fellowship who would-- in the state of California, we still have physician supervision laws in place. So, I needed somebody who would agree to supervise the physicians. And also, there was quite a bit that we could learn from our physician colleagues. So, Stanford is an academic medical center. We have resident learners and fellow learners that are becoming physicians at our institutions. So, it wasn't too far off from what our attending physicians were used to anyway. Many of them have requirements in participating with teaching. But it was really important to make sure that the department was open to this at the time that we wanted. Because it takes a lot of support, not only from the preceptors, but from the infrastructure, finance had to be on board, our CNO had to be on board. And then, we needed physician champions on board as well. And so, still to this day, we have a physician champion for each service line, and they participate in our quarterly advisory meetings as we're always trying to like tweak and make the program better and enhance it.

In terms of credibility for the APP, I think within our institution, what was really nice about the program, because the fellows are with us for a year, so it's a 12-month program I mentioned they rotate through different areas. And the way that we have cardiac surgery set up, they actually rotate through each area twice. So, the first time that the team of advanced practice providers or the physicians that are working with the fellow, especially early in the year, they're brand new and they're definitely novice and they're paired with a preceptor the entire year. And in that early part of the year, the preceptor's heavily involved. And so, that also helped. I think knowing that although the APP was a novice, that they had the support of a very experienced clinician alongside them. And then as the year goes on, that preceptor role really changes to become a little bit more in the background and allow the APP fellow to take on more and more responsibility as they've progressed. And then when the fellow does their second rotation back through an area, it's almost like they've metamorphosized into somebody different because they've now been in other areas, gained other knowledge that all feeds together because it's all related in the specialty. And then, they come back and now the team's like, "Wow, they learned a lot" and we're giving them more responsibility.

So, I think the credibility came just from the interaction that the whole team had with the APP fellow throughout the year. And then by the end of the year, most of the fellows were offered many positions on many different teams at our organization, which I think speaks to the fact that they really impressed all of our care team members with their performance.

Trisha Williams: That was going to be my next followup question. So, do the fellows apply for the fellowship program and then they would have to reapply for an actual job after their fellowship program? So, like how our physician colleagues work their fellowship programs, like they apply for a fellowship and then they apply for jobs elsewhere?

Megan Atashroo: Yeah, that's correct. So, the fellowship position, it's a 12-month term position. And then if they're interested in staying at the organization, we start to have those conversations with them around springtime as they start to think about where they're going to land and where they're hopefully going to stay for many, many years. So, they do apply to positions that they're interested in.

Trisha Williams: Do you have research or anecdotal information regarding retention? And you mentioned how you have preceptor satisfaction. Do you have any type of data supporting the fellows and how they feel like they are perceived or how they're accepted and how they feel like their knowledge was gained?

Megan Atashroo: So, one of the things that we do in cardiac surgery is we have a specialty-specific entrance exam that the fellows take during the first few weeks that we call bootcamp. They take the exam at the beginning of the year, middle of the year, and then at completion of the fellowship. And it's all didactic knowledge, like foundations, diagnosing, guidelines for surgery, operative techniques, and then moving into like how you manage lots of different postoperative issues. And so, we do have some really nice data from that that showed increases in their didactic knowledge in all of the areas at the end of the fellowship. And so, I think that that exam makes people nervous. But they also really like seeing their objective improvement at the end of the fellowship.

Other things we measure are their professionalism and pride in the role. I mentioned they complete an evidence-based project. And as we've progressed through various cohorts, that project is getting completed earlier and earlier. And so, actually, the last year, our fellows that graduated not only completed the project at the institution, but submitted abstracts and were speaking at national conferences on the work that they had done.

I don't have the data in front of me right now, but we do have data on the financial component or the return on investment. So, retention rates for those that were offered positions at our institution and how long they've stayed in those positions. And then also, measuring if they leave our institution, are they staying in the specialty in which they were trained to work? So, we're monitoring that and the data's getting more and more mature. Overall, I think our first specialty, cancer care, I think they might be in their seventh year right now, so seven years of data so far.

Tobie O'Brien: I really have enjoyed hearing about this. I think it's very exciting. I am really intrigued by all of it. One question I do have is you mentioned that you do the didactic sort of pre-test, mid-year test and final test. Is there a certification exam that is around for cardiothoracic surgery that you take that is geared for advanced practice? Or is this just something that you guys created?

Megan Atashroo: This specific entrance exam is something that we created. But that is a great question and that is something that we do utilize. So, we do want the fellows to have a certification at the end of their fellowship. There's not like the perfect thing that exists right now in the specialty of cardiac surgery. There's a certificate of added qualification that PAs can apply for, but you have to have a little bit closer to like three years of clinical experience before you can sit for that exam. But my colleagues in cancer, there is an exam that they take that gives them some certification. And then, for our EP fellowship that we just launched, they're all getting a certification as well. So, it doesn't exist yet for cardiac surgery, at least exactly what we would need or be eligible for at the end of one year. I think that sort of just speaks to how added certifications like that are still being developed, I think, for advanced practice providers. There aren't tons that exist. But it would be nice to have that just sort of as like the true stamp that like "I went through this program and I have this certification that demonstrates that I have this specialty knowledge."

Trisha Williams: And I think that they're there for nursing. They're just not there for advanced practice yet. There's a lot of work to do and maybe that that's something we could work on from our subspecialty standpoint. You know, Tobie and I are pediatric otolaryngology nurse practitioners, and we are very interested in doing a subspecialty certification for that. And maybe the work that you're doing with the fellowship program could lead to a nationwide advanced practice certificate.

Megan Atashroo: Yeah, I'm totally excited.

Trisha Williams: Lots of good work. I am a full supporter of advanced practice working to the full scope of their practice and being knowledgeable in the subspecialty that they work in. So, this subspecialty fellowship program is very intriguing to me and I think that it's something that across the nation that we could really all buy into and figure out how to roll that out at our own institution. I really love that. So, thank you for your hard work and dedication for those subspecialty programs.

Megan Atashroo: Yeah. And if I can give a plug, the applications are open right now for our next cohort. So, we have not just cardiac surgery, but I also mentioned electrophysiology, cancer care. A new specialty this year for us, neurosciences. And then, we also have an administrative fellowship at Stanford for advanced practice providers. And that's, I think, also really unique and something that we really need as well. And what that fellowship does, to qualify for it, I believe you need five years of clinical experience and it's to train APPs who want to transition into leadership. So, you're really going to focus on that leadership acumen and competency during your fellowship training year. So all of those, they're open right now if anyone is listening and interested.

Tobie O'Brien: Nice. I think that that sounds very exciting. I've never heard of anything like that, and how great of an opportunity, if that is the path that you're wanting to take. Well, we really have enjoyed having you on. I hope our listeners have found it very interesting and exciting for just the practice of advanced practice. I think that there's so much more and so much growing to do still, and so I'm excited for all of these fellowship programs that you have worked to create as well as hopefully more to come.

So as we finish up, we like to end each episode with the same question we ask each of our guests. And so, the question that we are going to ask you is: in what way do you love to encourage your colleagues?

Megan Atashroo: Such a good question. It's been a really exciting time to work in the advanced practice space. I think as there's been such a high uptick in utilization of advanced practice providers across the country in many different specialties, in many different settings. But sometimes it can feel like we're building the track as we go. Like you just mentioned, there's still some things that we can do to support our specialty. But I like to just encourage everyone where they're at in their current role to just do their part to lay the next brick. So if you're a frontline clinician, your brick is giving patients excellent care and helping to educate our consumers on what advanced practice providers are and what we do and how we're trained and what we can do for patients. If you're an educator or you're working to develop these fellowship programs or you're working at an APP program, your next brick is thinking about how we educate and prepare enough APPs to enter the workforce. And then, my role as leader, my role is really now to think about how do we set up the structure to support now this large workforce of advanced practice providers in healthcare systems.

So, everyone has a little brick to put down and it's building the foundation of what will be needed in the future to provide sustainable healthcare to increasing population. So, I think our profession is certainly a really important part of the healthcare landscape now and will continue to be.

Trisha Williams: I love it. It's an exciting time for advanced practice, that's for sure. And we all just need to lay our one brick down at a time and build that track. So, Megan, thank you so much for joining our podcast today. We've just had a great time talking with you.

Megan Atashroo: Thank you so much for having me. Hopefully, I'll see you maybe next year at Magnet.

Trisha Williams: Yeah, let's hope. We'll hope to connect.

Tobie O'Brien: Or over the 4th of July. You never know.

Megan Atashroo: Or over the 4th of July, yeah. If you see me at the fireworks stand, you know I'm back in town.

Trisha Williams: Yeah. All right guys. If you have a topic that you would like to hear about or if you are interested in being our next guest on the Advanced Practice Perspectives, please reach out to either Tobie or I at twilliams@cmh.edu or tdobrien@cmh.edu. Once again, thanks so much for listening to the Advanced Practice Perspectives Podcast.