The Evolving Role of the Nurse Practitioner in Cardiac Electrophysiology

In this interview, EP Lab Digest speaks with Julie Shea, MS, RNCS, FHRS, CCDS from Brigham and Women’s Hospital in Boston, Massachusetts, about her role as a nurse practitioner in the EP setting. 

Tell us about your medical background. How did you become a nurse practitioner?

My journey as a nurse began back in 1981 when I graduated from an AD program and started working as an RN at age 19. I’ve been at Brigham and Women’s Hospital since 1986, so I’ve been working here almost 34 years, 29 of those in cardiac electrophysiology. I feel privileged to have witnessed the explosive growth in the field over that timeframe. It’s been a fascinating part of my career seeing the entire span of implantable device therapy, from dual-chamber pacemakers, to ICDs, to resynchronization therapy, to where we are now with leadless pacing systems, as well as the advancement in arrhythmia management with catheter-based procedures. 

When I originally took over my current role as a registered nurse in 1991, it was actually a research position that evolved into a clinical position over time. I was working in the EP lab when I first took the job, and it was about that time — in the late 1980s or early 1990s — when we were starting to do defibrillator implants for the first time. While  working full time, I returned to get my Master’s as a clinical nurse specialist (CNS) from Northeastern University. Back then, you could either do a clinical nurse specialist track or a nurse practitioner track. When I was doing EP, it seemed to make more sense to do the CNS route. However, not soon after, it became clear that the advanced practice role was being consolidated into the nurse practitioner role, with phasing out of the clinical nurse specialist role. So, anticipating this change, I went back to school again while working full time, did a post Master’s program at the MGH Institute of Health Professions, and became certified as an Adult Nurse Practitioner. I’ve been practicing as an NP in EP for about 20 years now.

What is the role of the NP in the EP setting?

The advanced practice role as a nurse practitioner allows me to practice independently under the guidance of a supervising MD, which is still a requirement in the Commonwealth. I have my own panel of patients that I see. I do clinic four days a week at Brigham and Women’s, and I also see patients at a satellite center in Foxborough at Gillette Stadium. It’s great — I love the independent practice. One of the best things about working at an academic medical center is that I work very closely with my physician assistant colleagues as well as my physician colleagues who are supportive of the work I do. I have a lot of flexibility in my role, which enables me to provide independent evidence-based care to my patients.

How have you seen your role as an NP evolve?

When I first started in the device clinic back in the mid-1990s, I was functioning at the RN level at that time. But even when I transitioned over to an NP role, I was more of a physician helper at that time, so I would assist in the device clinic with a physician and do the device checks, and then the physician would come in and see the patient. I think that as the NP role and the field of electrophysiology continued to evolve with the addition of defibrillator therapy and ablation therapy, physicians were spending less time in clinic and more time in the lab doing procedures. So in order to facilitate that transition, it required having a capable individual in the device clinic or arrhythmia clinic to manage these patients.  Thus, it became the perfect venue for the nurse practitioner to be able to play a pivotal role in facilitating and extending the specialty care. 

What aspects of your work are most rewarding?

I think first and foremost are the patients — that is why I get up and come to work every day. I’ve followed many of these people for two and a half decades, so I have a well-established relationship with them and I love coming to see them every day. Probably the best part of my role is being able to work with patients and providing them with education about their disease processes and their device. When I enter the exam room of a patient with a newly implanted device, I can see the tense look on their face. As I explain things to them and they get a better understanding of what their medical condition is and how the device works, you can see his or her face relax. It really is a very powerful moment for me to be able to participate in the care of these patients, and see them do well and improve over time. I form strong relationships with my patients, which allows me to understand their needs and concerns, and I work closely with other members of their health care team to formulate comprehensive care plans for them. 

What are some of the unique challenges that NPs face?

I would say that staffing is probably one of the biggest problems that we have, and there aren’t any guidelines in terms of what is the appropriate patient load that a nurse practitioner should take on. I know there is a lot of discussion within the Allied Professional group at the Heart Rhythm Society. A common concern is “How many is a safe number to take, is it 1000 patients, 1500 patients, 2000 patients?” We don’t really have very good guidelines in terms of what is a safe number for a nurse practitioner or even an RN or a device tech to be able to manage. We really need to determine what are safe staffing levels, and I think we need some better data on that. 

For five years, I managed the entire device clinic care by myself, seeing 24 patients a day. It was a lot. Fortunately, we have brought on additional staff, so it’s much more manageable now. I have half-hour time slots instead of 15-minute time slots, so it allows me to practice more comprehensively and do a bit of a deeper dive on what’s going on with the patient. It’s much more than “just a device check.”

Also, from a professional standpoint, nurse practitioners in Massachusetts still have to practice under a physician, where in many states they are able to practice independently. I am hopeful that someday NPs will be able to have independent practice in the Commonwealth.

Tell us about your work as the program coordinator for the Living with Atrial Fibrillation (AF) program for Brigham and Women’s Hospital.

I think one of the biggest tenets of the nursing field is education. We are excellent educators; we identify the needs of patients and we’re able to meet those needs through proper education. I noted that many of our patients with atrial fibrillation had a lot of anxiety issues surrounding their condition, and I thought about how I could provide an educational experience to patients with AF. So we came up with this idea of having a half-day program that we would offer offsite to AF patients and their families, so people could come and learn from the experts. We rented out a ballroom at a hotel, and we’d have over 800 people come to these programs on an annual basis. It went over everything about atrial fibrillation — what it is and how to reduce stroke risk, as well as anticoagulation, devices for atrial fibrillation, ablation, the psychology of how to deal with the anxiety issues, and a question and answer session with our physician panel. It was a very well-received program. 

Most recently, the Brigham has been putting together the AF Center of Excellence, which came to fruition last year and is still a work in progress. As part of that, I wanted to resurrect the Living with AF program, but do it in a different format. So last September, we ran it here at the hospital, as more of an informal program where people could come in throughout the day and listen to lectures from our panel of physician experts. We also had several exhibits set up for patients so they could directly interact with vendors, and for example, learn more about the left atrial occlusion device and be able to see it, put hands on it, and talk about it with the vendors. We had vendors from anticoagulation companies, catheter-based companies, and device companies. We had our physician assistants teaching patients how to check their pulse and how to monitor and screen for atrial fibrillation. So we really tried to provide a comprehensive overview for patients, and it was very well received. We had a capacity of about 125 patients and family members, which we easily filled up. Due to the COVID-19 pandemic, this year’s program is virtual so that more patients will be able to log on from home and we can reach a broader audience, but keep it cost effective. It will be held on September 12th, during AF Awareness Month.

Why is the nurse practitioner a valuable asset in the EP setting?

I feel that NPs provide a significant benefit to any EP program, mainly because they are highly skilled practitioners. Most nurse practitioners in EP, since this is a subspecialty of a specialty, are very focused on just arrhythmia management, so we develop a highly tuned skillset in terms of managing our patients. All of our advanced practice folks here at the Brigham work independently, but collaboratively with our physicians, and our physicians trust us. So we have a lot of flexibility in terms of managing our patients, and I think that is one of the most valuable assets of having a nurse practitioner working in EP. 

Again, I think education also brings a lot to the table in terms of managing patients in electrophysiology. These patients have oftentimes faced near-death situations where they’ve had a cardiac arrest, and they were resuscitated and survived. They had the defibrillator put in, and now they’re back in clinic two weeks later and they’re absolutely terrified about what just happened to them. So there is a lot of the fear of the unknown, or if they’ve received an ICD shock, there is anxiety associated with that. I think that they appreciate our expertise and the holistic approach that nurses bring that provides a lot of reassurance to patients, trying to help them navigate through this new world. 

Contact the author on Twitter at @Ariat104.