Developing a Malignant Hematology and Bone Marrow Transplant APP Fellowship

Blood cancer cells under the microscope: © stock_acc - stock.adobe.com

The Malignant Hematology and Bone Marrow Transplant Fellowship at Miami Cancer Institute works to train advanced practice providers (APPs) to deliver high-quality, specialized care to acutely ill patients.

According to Janelle Vicens, DNP, APRN, FNP-BC, and Sandra Sepulveda, AGPNP-BC, MSN, BMTCN, this program began with formal disease-specific training for all existing APPs, who then transitioned into preceptors for new fellows. To enhance the fellowship, the institute is pursuing Advanced Practice Provider Fellowships Accreditation (APPFA) certification.

The fellowship aims to expand its vision to provide resources across various specialties within the organization, and leaders, like Vicens and Sepulveda, are committed to being pioneers in this field through encouraging other departments to adopt similar training programs. As the fellowship grows, they anticipate further improvements in patient care and increased interest from APPs in leadership roles, ultimately setting a standard for specialty training among APPs nationwide.

In an interview with Targeted Oncology^TM, Vicens, nurse practitioner for bone marrow transplant, malignant hematology and HIV oncology and program codirector of the Fellowship at the Miami Cancer Institute for Baptist Health South Florida, and Sepulveda, nurse practitioner, study coordinator for the Fellowship, discussed what went into developing this Malignant Hematology and Bone Marrow Transplant APP Fellowship.

Targeted Oncology: What inspired the creation of the Malignant Hematology and Bone Marrow Transplant APP Fellowship?

Vicens: We work with Marco A. Ruiz Andia, MD, and he is very passionate about education and training. He had a vision for this program, and in the past, our leadership has been interested in creating programs to better train our APPs. Personally, when I started in this department, I had my own insecurities as an APP. Transitioning from my background in oncology to bone marrow transplant and malignant hematology, I was looking for resources and support to feel confident and provide the best care to our patients. Over the years, many people contributed to this program and its development. Now, we are proud to have the resources in place to train our providers and to be able to provide better care for our patients.

How is the fellowship structured to train APPs in managing complex hematology and transplant cases?

Vicens: We have dedicated time to more interactive learning. While everyone has many hours of required learning, it is crucial to cover the material extensively. Therefore, we are focusing on providing clinical and didactic education that is also interactive. Our program includes lecture components, case reports that our fellows are required to complete, and abstract reviews. In the past, we have incorporated activities like a Jeopardy-style game during lectures, which encourages participants to self-assess their understanding of the topics presented. This approach helps them engage actively, rather than just passively absorbing information while sitting in a room.

We have also taken feedback from former fellows to restructure our learning format, dividing it by disease states. Instead of covering malignant hematology as topics arise, we are organizing our curriculum systematically, starting with the basics and gradually building up. Since everyone has a different background, we begin with fundamental concepts such as central venous catheters, cellular biology, and pathophysiology. We also include an overview of what to look for on a slide and introduce major emergencies before any hands-on patient interaction, ensuring that everyone is familiar with the essential information.

Our curriculum is divided on a month-to-month basis based on disease type. For example, when we focus on plasma cell etiologies, fellows will be paired with clinicians who specialize in plasma cell dyscrasias. This collaboration occurs alongside the clinical and didactic sections related to plasma cell dyscrasia. We will continue this approach with topics like lymphoma and leukemia transplants. We believe this method is a more effective way to break down the information, making it easier for fellows to digest and understand.

Sepulveda: There are multiple contributions to the fellowship program. As APPs and mentors, we provide hands-on instruction, guidance, follow patient assessment, treatment planning, and the day-to-day management of complex cases. During the rounds, we offer feedback and mentor. We were able to see good outcomes [for] patient satisfaction. We have been impacted positively on increasing the knowledge of the nurse practitioner, how to educate and communicate with patients and family members, especially when they are delivering difficult news or explaining complex treatment regimes. We are able to guide fellows and incorporate research into clinical practice. This program gives us the opportunity to involve the fellows in improving initiatives and taking the institution and patient care to another level.

Every program has its challenges, but we love to go with the challenge. The main challenge that we see in transitioning APPs to a presenter and educator is confidence in their teaching abilities, especially when they have just completed their own training. We provide support on effective teaching techniques. Balancing clinical responsibility with [protection] can be overwhelming for new APPs, and this may lead to burn out in some cases. The solution that we found for this situation is to structure presentership programs. This presentership program has been supported by leadership and also by our doctor, Marco Ruiz, who has extended experience in training fellows and serving as a mentor for medical students as well.

Another challenge that we have been facing with the fellowship program is the APP transitioning to preceptor roles. Sometimes they are worried about not having enough knowledge or experience to answer learners' questions. What I have been doing with them is looking to find solutions to these questions, like ongoing education and access to resources. I say, OK, do not worry. We can use [National Comprehensive Cancer Network (NCCN)] guidelines, different publications, articles, so we can be proactive in teaching and sharing information with fellows. Other challenges are role identity and professional growth. APPs sometimes may struggle with transitioning their identity from learner to teacher. They have been spending a considerable time focusing on clinical development. The presenter role is a key for professional development and can help an APP embrace the new responsibility. We get focused on the daily rounds, and we make sure that they feel comfortable transmitting information and educating the new fellowship.

What I have been seeing in my experience is learning how to teach individually, as everybody has a different style and pace of learning. I train in adult learning theory and technique strategies that can equip APPs to customize their approach based on the learner background and learning style. I use a lot of videos, try to make [learners] more connected with the questions and answers, and give feedback. The APP can deliver high-quality care, better manage complex cases, and improve patient outcomes in a specialized setting, like hematology or bone marrow transplant. Also, thanks to the fellowship program, every time we give the tools to the new nurse practitioner, the tools to the mentors, we are able to see that they get more involved and more interested in certification. If they get certification, they can have a high level of education and provide better care to the patients as well.

There are a lot of good things and important things that the fellowship program can bring to the institution that also decrease the turnover on the nurse practitioners, because when you are a registered nurse going to an APP role, it is a completely different word, but then, if you receive appropriate training, you feel more confident, have decreased burnout, and can provide better care to the patients. We were able to see greater attention and job satisfaction. I believe that having this fellowship program accredited and moving forward to the next level can help the entire institution and the patient care to improve and be more successful.

What are the other key challenges, if any, in transitioning APPs from learners to preceptors?

Vicens: It is the confidence. It is one thing to learn in the classroom and to go over what is theoretical, but that does not always translate to what you are seeing in front of you. There are a lot of things that you pick up in the clinical component, the clinical pearls, as they like to say, and so we that is why we like to pair the clinical component with the didactic component. What we are presenting later in the year is a tool that we developed to keep track of and to help guide our preceptors as they take on our fellows, because we do not want the feedback to be subjective. We want this to prepare fellows. We wanted to create more objective measures and metrics that our fellows needed to follow in order to successfully meet that rotation. This is going to help them feel more confident, because essentially, what we do is slowly let them fly on their own. They see that concept, how it is done, start to learn about the disease, start to get involved in the plan of care for that disease, and go through the differentials and what we are going to do with this patient. But towards the end of that rotation, we are just there to support you.

That helps, because they are practicing what they are going to be doing on their own when they are done with the fellowship. That is something that, unfortunately in our training programs, we do not get too much of because of liability and risk. They cannot be so hands-on with the patient, so they mostly observe and shadow. Some people might let them, but that reality is what it means to sit in that room when a patient asks you a question and you're the one providing the answer. What does that feel like? How do you prepare for that? What is that answer? And how do you develop that kind of care on something that's so dynamic? One can review the chart all they want, and they can prepare for that visit, and then the patient just comes out of left field with a new symptom that throws off that carefully thought-out plan of care that they had. Teaching them to be versatile and have dynamic plans of care, which comes from having a thorough understanding of the disease, if they truly understand what is going on, they can come from any direction, because they understand the disease and they have a good plan for that. We feel that our fellows are going to be very confident because we are giving them the tools to become confident.

How has the disease specific training impacted APPs’ clinical practice?

Vicens: I think it is definitely implementing a lot more evidence-based care and being introduced to the latest and greatest in our field. I personally went on maternity leave and came back to what seemed like a new world, because our field is constantly changing and evolving. So, teaching them how to go through the different indications of new drugs, go through the clinical trials, new treatments, how to stay updated and decipher these new products to see what is going to be best for our patients, what has better overall survival, and what is most beneficial? Even from an economic standpoint, what if both efficacy is the same, then what which product is better? Really, teaching our fellows how to stay updated in the latest and greatest management of our patients. Because it is disease specific, when we target it on a month-to-month basis, I think it allows us to be very thorough when we, for example, focus on plastic cell dyscrasias and the new [chimeric antigen receptor (CAR)] T-cell therapies, and the autologies, and the sequence of those orders, and things like that.

What outcomes are you seeing from the fellowship in terms of APP development and patient care?

Vicens: In APP development, we are seeing increased interest in scholarly work because we are active with research as part of our curriculum, in reviewing what is out there, I think they feel confident enough to now be a leader in the field and be a speaker at conferences and present their own abstracts or take on quality improvement projects, as Sandra mentioned earlier. These are all things that, because we expose them to it here, they feel more confident to continue taking on these projects and developing themselves as leaders in our field and in these areas. I know a lot of graduates have never had any exposure to these things, and it is not for lack of ability. They are great clinicians, but they do not have the confidence to be a speaker or to take on a quality improvement project or even know how to structure one.

We get to teach them that along the way as well, which I think equips them to take to feel more confident and scholarly work and publication, and then in turn, being able to provide them with the proper knowledge foundation theory in in the didactic components and the clinical parts, allows our patients to have more thorough, high-quality care, because we are not just learning on the go. We are certified providers, nationally certified, which means there are guidelines that keep us accountable to the different criteria that we want to meet in our program on a national level. When our patients come to see an APP, they're not just seeing an APP that decided one day to come into this field, but rather somebody who was trained and is certified to care for them. I think that is the center of what we do. It is patient care, and we can confidently provide high-quality care for our patients. Our patients will be well taken care of, and that translates to great outcomes.

Sepulveda: I believe also that the outcomes, the advanced training that the next practitioner receives there, will enable them to deliver more evidence-based care, which can lead to better patient outcomes. We are able to see reduced complications, faster recovery times, and overall improved patients. I believe that providing this practitioner with appropriate training, they help a lot to improve the patient's care. Also, they are able to understand a little bit better. The communication with different providers, social workers, physicians, different referrals, different specialists, they are more involved in the patient care, and they are able to better understand what we do on a daily basis and the importance of receiving appropriate training to provide better care to the patients.

With the fellowship program, APPs go through this training, they contribute to fostering a culture of continual learning and excellence within the organization as well. They get more interested in being part of the leadership program and bring positive ideas and ideas based on evidence-based practice to take care of our patients.

How else has the program affected the overall clinical health or clinical team at Miami Cancer Institute?

Vicens: It is the encouragement towards scholarly work and becoming a more academic-centered and focused team. It is not just a clinical day-to-day, but it is a preparation that goes behind that and moving forward. I think it encourages other departments to do the same. We have several other APPs now coming up to us with a lot of interest and leadership. There is a lot of interest now in developing this, because they see the value behind equipping our providers to provide better care for our patients.

Besides that, it gives us a national platform which keeps us accountable to what we are doing, and it allows us to share what we are doing with other cancer centers, other transplant centers, and encourages them to do the same. We truly believe this is the next wave for APPs. Our training is primary, and so when we go into a specialty, it is such an adaptation. We think it is going to be the next thing, and I think eventually, it will even be the norm, the standard for specialty trained APPs to be certified and go through a fellowship. We want to be a part of that movement. For our team, we are all working and pushing towards that goal and we continue to publish and speak in national areas and continue to preset the new fellows now that we are trained to train the next generation of APPs as they continue to come up and develop.

What are your future plans for the fellowship program?

Vicens: It is to expand our vision and be able to provide the same resources across all the different specialties. We share this vision with our leaders in our organization, who are also passionate about providing high-quality care. We look forward to being the rookie, the first ones to get this started, and then encouraging the rest of the departments to take this on as well. There are a few already in the works, so we look forward to seeing their success and as a group, just keeping each other accountable to giving the best possible.

Sepulveda: As a former fellow, I am grateful for the opportunity. I think it solidified all the areas where there were knowledge gaps that you do not realize daily, because you get to do the things, but you do not have a deep understanding of how things work. I am grateful to have had the opportunity to have come through the fellowship to learn those gaps and feel more confident in my abilities to practice, and now to be able to train other fellows as they come into the program to do the same. I hear our fellows are encouraged by the program. I think we share that passion, because our passion is to provide the best care, and we start that by preparing ourselves and putting the time in. We are excited to recruit, not just internally, but externally, knowing the opportunity to train individuals who may not have a fellowship program in specialty, but it is much needed, and so we can take you on and also offer the opportunity to have specialized trainers across the country. Eventually, we and our colleagues will help comanage some of our patients.