Lia Barros, NP - phaware® interview 452

Lia Barros, a nurse practitioner at the University of Washington, discusses the role of nurse practitioners in caring for patients with pulmonary hypertension. She emphasizes the importance of nurse practitioners in meeting the unique needs of patients with pulmonary hypertension and suggests that adopting collaborative care models can improve patient outcomes.

My name is Lia Barros and I'm a nurse practitioner at the University of Washington in the Pulmonary Vascular Disease Program. I wanted to talk to you today about the role of nurse practitioners in caring for patients who are living with pulmonary hypertension. 

I think first we can start with what is the history of nurse practitioners?

The first school started in 1965, and it was really to address the shortage of providers for pediatric care. I think we can see that over the several decades since then, the role of nurse practitioners has really grown and is flourishing. Now, you can see nurse practitioners working in the primary care setting, in specialty clinics like pulmonary vascular disease, inside hospitals as acute care providers. So that's anything from the intensive care unit to the general floor. They have a wide variety of practice, and therefore there's a wide variety of models on how to utilize nurse practitioners and their skillsets.

I always like to take a minute and also talk about what is the background of a nurse practitioner? I think that's one of the most common questions I get, even from other healthcare providers, is what is the unique role of a nurse practitioner, or what is the difference between nurse practitioners and physicians or physician assistants?

A nurse practitioner is an individual who had to obtain a bachelor's degree and become a registered nurse. Many of us have practiced as registered nurses across a variety of spaces before deciding to go for advanced education. Then in order to become a nurse practitioner, you have to obtain, there's two ways, either a master's in science in nursing or a doctorate of nursing practice. Then, once you obtain that education, of course you sit for a national license.

Some people then say, "Well, how come my nurse practitioner in one area or another seems to practice differently?"

I think that's an important thing that we talk about, because we have a full extent of our license, but that license is then regulated state by state. I'm so blessed in the state of Washington, we allow nurse practitioners to practice to the full extent of their license. We receive training and diagnosis treatment, health prevention, advanced communication, and advanced patient education. I'm really allowed to utilize all of that in my practice.

You'll see state by state that that varies. I'll speak to in the WWAMI region and in the state of Washington, because that is what I know. Nurse practitioners in this space are independent, licensed providers. So in the state of Washington, I'm allowed to practice on my own. That becomes really important when we think about the practice model. I do want to take some time to talk about that as well or share with you about that.

When we think about nurse practitioners in the role of caring for patients with pulmonary hypertension, we really don't have a consensus. So when you look across the nation, there's really no consensus or agreement on how to utilize this expert for best patient outcomes. What we do know comes from literature looking at nurse practitioners in the primary care setting, as well as there's some literature out there looking at nurse practitioners in cardiology. What we found is that nurse practitioners are competent, specially trained clinicians who are accessible with a hyperfocus on holistic communication and holistic treatment plans for the whole patient. When you look at patient outcomes for nurse practitioners compared to their colleagues, these outcomes show that the care is equitable or comparable. And in some areas, outcomes for patients that work with nurse practitioners is better.

I think it's really important that we fight against this notion that nurse practitioners are somehow a mid-level provider or a sub-performing provider, because it's not what the literature is saying. I don't think that's what patients are experiencing.

I'd say the last thing that we really understand is that in order for this multidisciplinary collaboration model to work, it has to require that the team members share common goals and values for their patients. I think this is huge, in that they share mutual respect for one another and of course, and then that they have excellent communication. So when we put that together, we find that nurse practitioners can be successful in a variety of areas, can perform the same or achieve the same patient outcomes if not better when they're empowered to practice to the full extent of their license in mutually respective environments.

Because there's no consensus in the PH community, I'll just take a moment to speak to my personal experience as being the first nurse practitioner in the pulmonary vascular disease program at the University of Washington and the first nurse practitioner in our pulmonary med specialties in general.

In our clinic, we utilize a collaborative practice model with a focus on high acuity patients. Well, what does that mean? That means that I am empowered to practice to the full extent of my license. I carry my own personal set of patients. And because of my time and accessibility, I focus on supporting the sickest patients across our entire clinic. Patients with pulmonary vascular disease, whether that's CTEPH, whether they're living with PAH, they have what we know is progressive serious lung and heart disease.

Because of the nature of this disease and its impacts on the patient's hemodynamics and their overall day-to-day life, most of our patients are out living in the world with severe heart and lung disease. They struggle with things like volume management, lifestyle modifications, limiting their salt, limiting their fluids, weighing themselves, taking these complex medications, titrating on medications with serious side effects, all of which really require intense available support from their providers. So what we have found in our clinic is that our patients are doing better when we have somebody who is competent and able to respond to those urgent needs.

We really are finding that my role has allowed our whole team to provide more preventative care, to intervene earlier, helping avoid hospitalizations and really improving outcomes for our patients across the board. I think that when we are asking ourselves, how can we best utilize these different experts in medicine, in healthcare, the answer is that we need to create solutions that allows each person to bring their expertise and to meet the needs of our patients.

In our clinic, this is the model where we have found success. So again, it's my ability to get to have the time to really meet the unique needs of patients who are living with pulmonary hypertension. I would probably argue that all of our patients, even the ones that aren't struggling with critical illness in the moment, would probably benefit from working with their nurse practitioner in their clinic, because probably all of our patients with pulmonary hypertension warrant very intensive care in their day-to-day.

Another way we use this model is in addition to carrying my own patient cohort and covering the high needs of the patients across the clinic, I also have capacity to consult on the inpatient side. That means that when our patients are admitted to our hospital or to some of our smaller hospitals in our neighboring states, I'm able to engage or fill the role as a consultant. At the University of Washington, we really cover what we call the WWAMI region. That means we cover patients that are in Washington, Wyoming, Alaska, Idaho, and Montana, which you can imagine is quite a large range. We work a lot with small community hospitals, local providers. Considering how rare PAH is, there is a lot of need to support our colleagues in caring safely for our patients.

So by having this care model where I have the ability to work with our high need patients, that also gives me the ability to work with local providers to support them in caring for patients with pulmonary arterial hypertension in a unique way we were not able to do as well before. I also consult for our patients when they're in the hospital, helping guide their pulmonary vascular disease care, as well as helping when they find themselves in an emergency room in their town or on their way to us.

I don't come from a background of healthcare providers. My mom got diagnosed with metastatic cancer when I was about 18. My first exposure to healthcare providers was watching those that cared for her through the end of her life. I would see my mom have these difficult days, and the people that were there to comfort her and support her were nurses. I remember sitting in this infusion room with her and she was crying. It was a difficult space. You could see patients of all points of their disease. I think for her, she could see the trajectory of where she was heading. I was only 20 maybe at the time and didn't know how to comfort her. I saw this nurse swoop in and hold her and say, these simple yet profound things that completely calmed my mother, gave her peace. I just thought to myself, "Oh my God, I want to do that for people."

The next day I enrolled in my nursing program and then was more exposed to the different types of nursing. I've always enjoyed academics. I've always enjoyed the challenge of education and learning, and I really felt that critical care did two things for me. Working with critically ill patients gave me the satisfaction of challenging me intellectually. At the same time, it allowed me to support families and patients through death and dying. I think one of the things in losing my mom at a young age is that it has made me so aware of the presence that a provider can have and the lasting impact that they can make in trying to help hold that grief and move you through that grief. One of the things that attracted me to the ICU was that I got to do both those things. I got to have these deep connected conversations with strangers on some of their most difficult days. Simultaneously, I was learning and growing and constantly challenged by the new thing that I was facing in front of me.

I practiced as a critical care nurse for about 13 years before I became a nurse practitioner. I intersected with patients living with pulmonary hypertension once they had hit the ICU or critical illness. I always found these patients to be young, resilient and really remarkable people living out their lives struggling with a very serious illness. I think I was first drawn to pulmonary vascular disease, because I was drawn to the patients. I was drawn to that therapeutic relationship and caring for patients in the ICU. I think it was a natural then progression that when I became a nurse practitioner, that I was attracted to working in pulmonary vascular disease field because it is a complex disease. It challenges me to understand physiology which I'm interested in. Patients are critically ill and yet out living their lives in our community, meaning that I felt that the nurse practitioner role could really support patients to stay out of the hospital living their lives.

I think it felt like a natural progression from the intensive care unit to a place where I wanted to grow my own practice, caring for critically ill patients that are living out in the community that have very complex physiology that challenge me both intellectually as well as emotionally caring for such a really remarkable group of people.

I think just overall, what are the two things I really hope to communicate is I think that nurse practitioners are specially trained, accessible, and competent clinicians. When we operate in these collaborative care models with mutual respect and supported to practice at the full extent of our license, patients do better.

I also think that patients living with pulmonary hypertension have unique needs that nurse practitioners can meet, because of that competence and accessibility. I think that programs across the country would see an improvement for their patients if they adopted this collaborative model and really supported and celebrated the role of nurse practitioners in the care of patients with pulmonary hypertension.

My name is Lia Barros, and I'm aware that I'm rare.

Learn more about pulmonary hypertension trials at www.phaware.global/clinicaltrials. Follow us on social @phaware Engage for a cure: www.phaware.global/donate #phaware
Share your story: [email protected] @uwepidemiology