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.
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