In this feature, we profile a particular type of nursing so that others in the field can learn about what nurses do in this position, what they enjoy about it, and how others can get into it.
Kathleen Martinez, MSN, RN, CPN, President, American Academy of Ambulatory Care Nursing (AAACN), and an infection preventionist at Children’s Hospital Colorado, gave us information about ambulatory nurses.
What is ambulatory care nursing and what do they do?
Ambulatory care nursing is unique in that it treats an individual in this fuller context of community, family, and population. Ambulatory care considers the access and quality of health care, but also evaluates the influence of other social determinants of health: economic stability, neighborhood environment, social context, and access to quality education.
I was introduced to ambulatory care nursing when I accepted a position in Children’s Hospital Colorado Telephone Triage Center. In telephone triage, an RN uses the nursing process (assessment, diagnosis, plan, implementation, and evaluation) to determine the significance of symptoms during a phone call. Every call requires all your skills and creativity. Each encounter requires total focus and attention; interpreting and clarifying information, considering availability of resources, navigating barriers, ensuring that the family understands the care instructions, or that they have called 911, or that they have transportation available to get to the ED or clinic.
And all of this is done within an eight-minute phone call, with a family you may never have met before. I was hooked! It is incredibly empowering and humbling to walk with a family through a child’s illness.
All state Nurse Practice Acts define “Dependent Practice” in circumstances where RNs are carrying out the orders of another provider, such as an MD, Advanced Practice RN, or Physician Assistant; and “Independent Practice” in circumstances where RNs are using their knowledge, skills, and training to initiate and complete tasks within the scope of nursing. Ambulatory care lives much more in the “Independent Practice” realm.
As an ambulatory care nurse, what are your responsibilities?
Well, that depends on your role. If you have a role in Care Coordination and Transition Management (CCTM), you might be checking lab results for a patient, or adjusting their medications based on those results. You may visit a complex patient in an inpatient unit who is preparing to transition home or to an extended care facility. Maybe you are doing a home visit to ensure a family can properly deliver the medications and treatments their child requires.
If you work in a clinic that performs procedures, you may be teaching a preoperative class. Or completing a post-operative wound assessment. Or completing a procedure, such as a fecal microbiota transplant in a GI clinic, or phototherapy in a dermatology clinic. Or performing a prenatal exam or well child check in a Federally Qualified Health Center.
What many people don’t understand is that the acuity of care performed in the ambulatory care setting is similar to care delivered during an inpatient stay. In fact, more than 80% of all cancer care is delivered in ambulatory care settings, including high-dose chemotherapy, preparative regimens for bone marrow transplants, and radiation therapy.
According to the Center for Medicare and Medicaid Services (CMS) 70% of all surgeries occur in an ambulatory setting. Clinics perform complex procedures such as bronchoscopies, endoscopies, and dermatologic surgeries. In all of these settings, RNs use the nursing process to provide care, education, and support.
What are the biggest challenges in being an ambulatory care nurse?
One major challenge: Broadening the scope and job responsibilities to accurately reflect our education, training, and licensure.
Federally Qualified Health Centers and Rural Health Centers are role models in allowing nurses to work to the top of their license. Nurses perform well-child checks, routine pregnancy care, and Medicare Wellness visits. They perform screenings and manage medications with the use of Standing Orders. They teach classes on managing chronic illness. They coach, encourage, and engage individuals to take charge of their health and wellness.
Other ambulatory care settings are learning from these models and creating exciting and engaging roles for RNs.
Another major challenge: Reimbursement for services remains a frustration for nursing in all settings and is a primary focus of the American Nurses Association and the Future of Nursing 2020-2030.
What are the greatest rewards in being an ambulatory care nurse?
The promotion of health and prevention of disease occurs over a lifetime, not in a single episode of care. Ambulatory care nurses meet people where life is lived: in schools, community centers, clinics, and in their homes. We walk alongside individuals through a season or a lifetime as mentors, peers, and teachers.
Statistically, only a small percentage of people are hospitalized each year, yet greater than 90% of Americans seek health care services in ambulatory care settings. And we are there to meet them!
When I was performing telephone triage, one of the most impactful statements I could make was saying, “It sounds like you are doing a great job.” Or simply, “Your child is lucky to have you as her parent.”
Creating this space of honor and trust allows the family to interact truthfully, which allows us to provide better care. It also just feels amazing to hear the relief and gratitude in the voice of the caller when their efforts are recognized and appreciated.
If nurses want to pursue a career in ambulatory care, do they need any additional education and/or training?
A Baccalaureate Degree in Nursing provides much of the knowledge and skills needed for any nursing role, including ambulatory care nursing. A strong “Transition to Practice Program” fills in any gaps and focuses on additional training. Just as critical care nursing is a specialty, ambulatory care is a specialty, requiring ongoing education and training.
AAACN offers tools and resources to support orientation and we have developed a very popular ambulatory care nurse residency program. We also provide extensive support via education events, networking/special interest groups, and targeted publications for those interested in pursuing a career in ambulatory care nursing. I always advise nurses to join an association supporting their specialty to open career doors and bond with colleagues.
To further advance the specialty, AAACN is working with the American Association of Colleges of Nursing to ensure all prelicensure programs include adequate material and experience in the ambulatory care setting.
What kind of advice would you give to a nurse wanting to work in ambulatory care?
I have been in ambulatory care-specific or associated roles for 30 years. Every year the opportunities are expanding. The Affordable Care Act of 2010 was a game changer. After half a century of hospital-focused care, there was suddenly a shift to health maintenance, disease prevention, care coordination, patient-centered care, and looking at social determinants of health as a larger context of care.
The Future of Nursing 2020-2030 calls for an increased focus on the role and value of the RN as a member of the health care team. During the 2019 Future of Nursing 2020-2030 Town Hall meetings, the focus was almost entirely on elements central to ambulatory care: environment, community, access to health and education resources, management of chronic diseases, and wearable technology. In addition, it’s important that patients are cared for in a comfortable and familiar environment. Use of telehealth specialty care decreases the burden and cost of travel. Telephone triage and telehealth visits allow sick persons to remain at home in comfort while accessing high-quality and reliable care. In some states, use of Standing Orders greatly expands the care that can be provided by the RN.
There’s a nursing shortage that is not only affecting the United States, but the entire world. And research is showing that it could to get worse.
That’s why it’s crucial for nurses to stay happy and not completely burnout. And it’s not only up to them to stay that way, but for their employers to keep them pleased and working as well.
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN, Chief Nurse of Health Learning, Research & Practice at Wolters Kluwer, an acute care/critical care nurse practitioner at Penn Medicine, Chester County Hospital; a clinical adjunct faculty member in the graduate nursing program at Drexel University, and author of COVID-19: Transforming the Nursing Workforce in the New Paradigm of Care took the time to answer our questions.
What could the current nursing shortage mean for hospital care quality?
The nursing shortage is actually a global issue. According to the latest research, it is estimated that the world will need an additional 13 million nurses by 2030; in the U.S., the need is projected to be 1.1 million (International Council of Nurses). There are several reasons for the nursing shortage. As the population of the world increases and Baby Boomers continue to age, the need for care will increase. This is compounded by the fact that nursing schools around the country are struggling to meet the rising demand for nursing education due to limited faculty, resources, and clinical sites; they turn away an estimated 80,000 qualified applicants each year in the U.S. due to this supply and demand issue (American Association of Colleges of Nursing). A large portion of the nursing workforce was set to retire in the next 10 years. However, the pandemic has accelerated this event, and nurses are leaving sooner than expected due to widespread burnout and exhaustion.
If nursing staff are feeling overworked and undervalued, they will more readily leave their institution, and perhaps the nursing profession altogether. This, in turn, increases the current nurse shortage, and the problem continues to worsen. Hospital care quality suffers if nurses are burnt out and overwhelmed, just as it suffers if nurses are missing. Patient wait times increase, and bedside care suffers. For hospital care quality to improve, there needs to be a concentrated effort to fix the supply and demand issue in nursing education, and there needs to be a concentrated effort on workforce well-being and fostering resilience—that is the bottom line.
What can hospitals/medical centers do to increase resilience among their existing nursing staff, while making sure that they don’t burnout and leave?
To foster resilience among the workforce, organizations need to acknowledge there is an issue and focus on workforce well-being. This means providing a safe environment in which to practice and provide patient care. Providing adequate staffing based on acuity/severity of illness and competency not just on numbers is the first step. Building up float pools that are cross-trained to work across adjacent specialties and move from one area to another is essential. While nurses do not like to float outside of their units, in an emergency or disaster situation, having the staff cross-trained to work in adjacent specialties helps to create an agile, efficient workforce.
Health care institutions need to invest in their workforce. Providing adequate breaks, healthy meals, self-scheduling, shorter shifts, and being able to take time off is crucial to preventing burnout. Nurses want to feel valued—providing continuing professional development activities and having the ability to meet career goals with lateral or vertical moves can make the difference between keeping the talent and losing it.
Health care systems must recognize when burnout and moral distress are occurring. That means having trained personnel up on the units evaluating what is really happening and then providing mental health support through employee assistance programs. Often nurses are worried about their families; health care institutions need to provide alternative child or family care or even financial planning. Burnout can be prevented or at least minimized if health care institutions are actively on the lookout for it, address the issues that cause it and invest in their workforce well-being.
How can nurses prevent their own burnout? Especially when hospitals, etc. are understaffed?
Preventing burnout is no small task, but nurses can certainly take steps to reduce their stress and prioritize self-care when they feel overwhelmed in the workplace. It’s important for nurses to know how to evaluate their own well-being, recognize their limitations, and be able to advocate for themselves when something is beyond their bandwidth.
Learn to be comfortable with saying, “No.”
Saying no is one of the hardest things for nurses to do; we are a caring profession and we often sacrifice our own self-care to care for others. We need to understand that if we don’t care for ourselves and find our own inner peace, there will be no one left to care for others.
Personally, I recharge by finding my inner peace and joy by reading, enjoying the outdoors, and sitting by water. Reclaiming “me time” within my day to recharge allows me to show up fully ready for my next day of work.
What are some proven strategies for creating a more agile workforce that both addresses the nursing shortage as well as avoids reliance on traveling or temp nurses?
The agile care model is based on patient acuity, competency of the workforce, and alternative care delivery models. It provides agility that allows hospitals to move their nursing workforce when and where they are needed and uses other members of the health care team to support patient care such as unlicensed assistive personnel, licensed practical nurses, and others. It also switches the care delivery model from a primary nurse model to a hybrid team model of care as needed.
The backbone of this model is cross-training the float pool to work across adjacent specialty areas and as a backup, having the full-time staff cross-trained to work across adjacent specialties in an emergency situation. This interdisciplinary team-based approach facilitates the rapid deployment of staff to areas most in need in a crisis, such as what we’ve experienced with COVID-19, and provides better care for a greater number of patients.
This addresses the nursing shortage by improving the quality-of-life nurses experience at their workplaces. With more nurses trained to work in adjacent areas, staff will be able to take time off and recharge. When nurses feel practice-ready, confident, and able, they are less likely to burn out because they will experience less overall stress at work. Health care institutions must also be on the lookout for early signs of burnout and encourage their nurses to take time off when it is needed.
What are the biggest mistakes that hospitals/medical centers can make with their current staff that could lead faster to burnout and them leaving?
Health care organizations need to understand that their biggest asset is their workforce. Without nurses and other medical professionals, hospitals and medical centers cease to function. Nurses need to be recognized for their value—their workplaces should support them by looking out for signs of burnout, offering mental health support, offering family/childcare support, and encouraging a healthy work-life integration. Without these basic acknowledgements, it is no surprise the burnout and shortage levels are what we are seeing today.
Nurses’ mental health matters! Nurses need to talk to their organization and be vocal about how they can better support their nursing teams. Whether that is more frequent review of their workforce policies, more transparency in the workplace, or more vacation time, nurses shouldn’t be afraid to speak up and stand up for themselves and for their fellow nurses.
Anyone who was around that day will always remember what they were doing when they saw or heard that planes had hit the Twin Towers in New York City on 9/11. For days, people tried to find out if their loved ones were okay. For months, the nation worried about other terrorist attacks, like those that happened in NYC or the plane that crashed into the Pentagon or the one that crashed in Shanksville, Pennsylvania. And for years, we’ve remembered and commemorated the day—to grieve those who were killed and to thank those who helped.
But imagine if you were working as a nurse in New York City on that day.
Pritee Rudnick, RN, was working as a nurse at Lenox Hill Hospital on the Upper East Side of New York City on a surgical telemetry floor on September 11th. “I remember we were waiting for patients to come in, but not too many came in—our ER only saw minor casualties. We tried to discharge the stable patients to prepare for any major casualties to come in,” Rudnick recalls. “I remember I was in a patient’s room. I was suctioning their airway Trache and facing the patient, when [I noticed] the patient was clearly upset from watching the news. I found out as the patient was watching the news, and I had to calm the patient and my other patients as they were too upset about the news of 9/11.”
She also remembers: “It was a very weird, sad feeling as we were preparing for major casualties, but those went downtown closer to the Twin Towers, mainly to NYU. I remember days after going to the hospital felt very strange and sad to know how many peoples’ lives were lost. As the years have gone on, I will never forget working that day.”
Rudnick still works at Lenox Hill Hospital. “There has been a huge turnover of staff since 9/11, and the senior staff has always been in sympathy of those times. But since we see so much all the time, we have moved on from 9/11,” says Rudnick. But I will always remember that day, especially since this past year has been very difficult on staff from the pandemic.”
As the 20th anniversary of 9/11 arrives, let us remember all the nurses who were working that day—whether they were close to the front lines or not.
As the Delta variant of COVID-19 spreads and numbers of those infected and being in treated in ICUs across the country keeps getting worse, it’s important for those not vaccinated to do so.
The American Nurses Association (ANA) recently spoke out and took a stand—stating that nurses should get vaccinated.
ANA President Ernest J. Grant, PhD, RN, FAAN, took the time to answer out questions about this and why it’s so important.
Why did the ANA feel the need to come out in favor of nurses getting the vaccine for COVID-19?
ANA has a longstanding history and commitment of supporting immunizations to protect nurses, health care professionals, and the public from highly communicable and deadly diseases—and COVID-19 is no different. For our nation to recover, heal, and return to a semblance of normalcy, enough individuals, nurses, and health care professionals must get vaccinated against COVID-19.
The swift development of COVID-19 vaccines and the execution of mass vaccination efforts is a significant public health victory and a scientifically proven strategy to slow the spread of COVID-19 and prevent the loss of more American lives. ANA continues to implore all health care professionals and the public to follow the science, adhere to the latest guidance of public health officials, and get vaccinated against COVID-19.
As we’ve seen, there are nurses and other health care workers willing to lose their jobs when they are required to get the vaccine. Why is this problematic?
It is very disheartening to hear reports of nurses who are willing to quit their jobs rather than get the COVID-19 vaccine. There is significant clinical evidence on the safety and effectiveness of the authorized COVID-19 vaccines being administered under the Food and Drug Administration’s (FDA) Emergency Use Authorization (EUA). To those who are apprehensive about taking a COVID-19 vaccine, I say trust the science and evidence. What is more, the pillars of patient-centered care and the nursing’s own professional standards ethically obligate nurses to model the same prevention measures that nurses recommend to their patients.
Nurses play a critical role in the monumental recovery efforts currently underway to end the COVID-19 pandemic. Our nation will only be successful in recovery efforts with a robust nursing workforce at peak health and wellness, providing safe patient care, administering COVID-19 vaccines, educating communities, and setting an example for millions of Americans.
There are nurses who don’t believe the vaccine works. What can other nurses say to them to help them understand?
It is paramount for nurses to remain knowledgeable and up-to-date on the science behind the vaccines, and the ongoing clinical studies that prove its efficacy. ANA has developed key principles to guide nurses and other health care professionals’ consideration for COVID-19 vaccines. These principles provide recommendations for access, transparency, equity, efficacy, and safety of COVID-19 vaccines. Additionally, ANA’s comprehensive COVID-19 vaccine resource page stays up-to-date on the latest clinical information and news. ANA has also created a focused video education series on COVID-19 topics, covering different aspects of this crisis and providing information that nurses can apply immediately when caring for COVID-19 patients. ANA’s COVID-19 videos are FREE for all nurses.
Has the ANA received any backlash from nurses about this stance?
We are seeing more and more nurses getting vaccinated. And based on what we’re hearing from our state associations, organizational affiliates across the country, and our most recent survey, nurses are in favor of the vaccine mandates and trust the COVID-19 safety and effectiveness of COVID-19 vaccines.
Tell us about the support that the ANA has received from this stance.
Nurses working across all areas of the health care system are disseminating culturally relevant information on the COVID-19 vaccines to the communities and patients that they serve. Nurses are connecting with their patients every day to have meaningful conversations and answer questions about COVID-19 vaccines. ANA applauds those nurses who are getting vaccinated against COVID-19 and proactively setting an example for their patients and the public.
Is the ANA’s hope that other health care associations will follow their example? Why would this be important?
We strongly encourage other health care organizations and health systems to support of mandatory vaccinations against COVID-19 for all health care professionals including nurses.
Most importantly, we urge everyone to follow the evidence and science, so our nation can continue making progress in recovering from this pandemic to restore our health care systems and communities.
While the worst of the COVID-19 pandemic seems to be behind us, the spread of the Delta variant indicates that it’s not completely over yet. During the height of the pandemic, nurses worked on the frontlines all over the country, and some are just now sharing their experiences working in the ER during the height of COVID-19.
Rastisha Smikle, RN, works in an ER at a hospital in central Florida. Having worked as a nurse for more than 10 years, she answered our questions about what it was like in the ER during COVID-19.
As a nurse in the ER in Florida, what has it been like working there during COVID-19? How has it changed over the last year or so?
It was very challenging to work during the pandemic. In the ER, we are a patient’s first point of contact, and because of that, our staff is considered at a higher risk of being exposed to the virus. Although safety and infection control elements have always taken priority in our roles, the unknown factors of the virus’ transmission, ever-changing symptomatology, and treatment contributed to our challenges because of all the unknowns.
Patients were more fearful than ever; they often came in anxiety-ridden wanting testing because of recent exposures, which added additional challenges because the critical emergencies also relied on our care.
In some ways, things have gotten better. As we have learned more about the virus and therapeutic treatments, patients are being cared for more efficiently so that they can recover at home. Unfortunately, hospitals nationwide are busier than ever right now. The volume that we are seeing is higher now than we saw during the pandemic. It’s tough to say what that is.
Did your duties change during COVID-19?
My duties didn’t change per se, but the way we cared for patients did.
Before the pandemic, PPE like N-95 masks were not permanently a part of my uniform. Now, I wear an N-95 and face shield with every patient encounter. Because of the wide range of symptoms, we have to be extra diligent in caring for patients just in case they have the virus and aren’t aware of it yet. In addition, minimizing my exposure time with known Covid-19 patients is also an element that I have had to implement in my care. For the safety of myself and the other patients, swift patient care must be implemented with these patients when appropriate.
Employing the use of hospital phones has been a way that I try to fill in the gap. Throughout this time, I have learned how fearful patients are after they get the diagnosis. With these talks, I can extend some reassurance, listen to their concerns, and figure out thoughtful and effective ways to help them with the emotional challenges that often accompany the diagnosis and isolation.
Was it scary to work there in the beginning of the pandemic? Why?
There was a level of fear when it came to the unknowns. I had worries about getting the virus. But primarily because of my level of exposure in the ER, I was mainly concerned about others being around me. I isolated myself from family and friends, and my life was work and home.
There were times when we would care for patients with no known symptoms and later, we’d find out that they were positive for Covid-19. I would have mounting thoughts of whether I wore the correct PPE or if I was exposed in those moments.
We also had staff members contract the virus, which was scary. Thankfully, most of them recovered well, but seeing how careful other staff members were and finding out that they still contracted the virus was nerve-wracking. Every minor allergy symptom or cough would cause concern and anxiety about whether I was next. To combat those fears, I had to reshape my focus. Instead of being hyper-focused on getting sick, I began to fix my focus on doing my job well and providing the optimal patient care that I was used to. With this newfound focus, my anxieties slowly began to dissipate.
How do you keep yourself from bringing the stress of the job home? What do you do to relieve your stress?
Sometimes it can be challenging, especially after losing a patient. My go-to stress reliever is prayer. I have a solid spiritual foundation, and thankfully the organization I work for also provides spiritual support, if needed. As nurses, we are fortunate enough to work three shifts per week. I try not to take my days off for granted; I use that time to refuel. Therapy, exercise, and self-care activities have been essential to my mental well-being.
What are the biggest challenges of your job—especially during COVID-19?
One of the biggest challenges of my job is knowing that I have to be on my A-game at all times because the safety of myself and others depends on it. The unknowns that came along with COVID-19 made it challenging to do and be our best. For example, we didn’t always know the best course of action when treating some patients because everyone would respond so differently, which posed one of the biggest challenges. Thankfully, as time went on, we learned more about the virus, the treatment options that worked for others, and we eventually adapted very well.
What have been your greatest rewards during this time?
My greatest rewards have been seeing how the nursing and healthcare community banded together during the most challenging times. The support from our community members was also very inspiring. We often came into work with goodies from companies that wanted to encourage and thank us for our continued work.