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.
Public health is an important aspect in the nursing profession because it involves addressing medical illnesses on a global scale. Due to the aging population and the advancement of medical technologies, public health nurses are vital in developing and providing skilled nursing care aimed at promoting preventative measures to increase the global health of the population. It is this understanding that fuels public health nurses to continue their efforts to not only educate society about certain illnesses, but also promote healthy lifestyles across the patient gamut.
What is Public Health?
According to the Public Health Institute, public health is defined as “the science and practice of protecting and improving the health of a community, as by preventative medicine, health education, control of communicable diseases, application of sanitary measures, and monitoring of environmental hazards.” The focus of increasing public health awareness is significant especially in today’s society because of the growing paradigm shift towards preventative care versus diagnostic care. In addition to this, public health awareness also requires a collaborative and multidisciplinary effort consisting of physicians, epidemiologists, statisticians, and dietary professionals. This interprofessional collaboration is vital because it involves gathering a sizeable amount of clinical data to effectively screen and prevent a disease from adversely affecting the general public.
The Impact of Nursing in Public Health
The impact of nurses in supporting public health efforts is invaluable because of their strong emphasis on health promotion and disease prevention. Nurses not only possess the proficiencies but also competencies to tackle the burden of health determinants and the various environmental and behavioral factors associated with it. Subsequently, nurses must have the skillset to proactively confront these challenges within an individual and societal context. In order to evaluate these activities, nurses must be diligent in both planning and implementing to ensure public health concerns are addressed directly. Finally, nurses who are actively involved in lobbying for societal and structural reform are then able to promote effectual health care strategies aimed at reducing negative health outcomes associated with poor health decisions and a lack of knowledge.
Why is Public Health Important?
Due to the health care industry shifting towards more preventive care strategies, nurses continue to play a major role in leveraging public health awareness. By identifying and monitoring health concerns that may affect entire communities, public health nurses are uniquely qualified to not only advocate, but also promote societal change to safeguard the health and well-being of all individuals around the world. Therefore, a nurse’s role in health promotion includes various responsibilities related to advocating, enabling, and mediating activities to ensure salubrious decisions equate to healthier outcomes.
Medical terminology can be overwhelming, and despite the best efforts of nurses and doctors, a lot can get lost in translation. Now, for the first time, patients will have access to the notes doctors have made in their medical records through OpenNotes. The initiative, designed to improve communications between medical professionals and patients, is currently being tested in Massachusetts, Pennsylvania, and Washington State. Over 100 doctors and 25,000 patients across the three states are currently testing the project.
“People remember precious little of what goes on in a doctor’s office,” Dr. Tom Delbanco, M.D., at the Beth Israel Deaconess Medical Center in Boston, Massachusetts, notes during a video tour on the project’s website (http://myopennotes.org). “It’s a high-stress situation for everyone, whether healthy or whether sick, and there’s lots of data that shows the memory for what happens in the doctor’s office or in the nurse clinician’s office is not very good.” Delbanco stresses the relaxed approach that home access brings. Via a secure website, patients can browse doctors’ notes at their own leisure.
But what does this newfound access to information mean? OpenNotes is more than just a digital record of physicians’ notes; it provides a streamlined way for patients to interact with their prescribing doctor. Doctors can update their notes after follow-up visits, phone calls, and e-mail correspondence and keep a cohesive record of everything the patient is experiencing. Notes can be presented in a variety of forms, including recorded sound bytes created by the doctor after the visit. It also gives patients the chance to double-check accuracy of notes in their file and correct errors more quickly.
However, many patients don’t even know that they have the legal right to view their doctor’s notes, the result of 1996 legislation under the federal Health Insurance Portability and Accountability Act (HIPAA). As the project continues its test run, there is a clear goal in mind: “The bottom-line evaluation of OpenNotes, to be assessed primarily through Web-based surveys, is straightforward: will patients and providers want to continue online access to notes when the year-long study ends?” says a perspective compiled by all participating doctors published in Annals of Internal Medicine.
“I think this may be a real step in transforming the patient and provider relation,” Delbianco says. “There’s lots of talk about shared decision making, there’s lots of talk about leveling the playing field, there’s lots of talk about not talking down to those whom we serve…My own hypothesis is that we’ll make for better health care and for healthier patients and a healthier citizenry.” Hypothesis, noted.
In recent years, the relationship between oral health and overall wellness has teetered on the edge of public awareness. Now, the U.S. Department of Health and Human Services is launching an initiative aimed at making it a top priority. Eight HHS agencies, including the Office of Minority Health, the Administration for Children and Families, and the Surgeon General, are collaborating to support and expand oral health education and research. In particular, they hope to make oral health care services more widely available to underserved communities. Racial and ethnic minorities continue to be disproportionately affected by oral disease, and a significant facet of the initiative is working toward eliminating these disparities.
In April, Assistant Secretary for Health Dr. Howard Koh addressed the crowd at the National Oral Health Conference in St. Louis, Missouri, introducing them to the effort and its overall theme: Oral Health is Integral to Overall Health. Dr. Koh called the deficiencies in oral hygiene a “silent epidemic,” noting that 53 million people in the United States currently have untreated decay in their permanent teeth. Working with Dr. Koh in leading the initiative is Dr. Mary Wakefield, the Administrator of the Health Resources and Services Administration, in conjunction with the U.S. Public Health Service Oral Health Coordinating Committee.
Initiative goals and activities include creating campaigns that promote oral health and disease prevention and supporting oral health care professionals. Among individual agencies, the Indian Health Service will strengthen its Early Childhood Caries initiative, including monitoring childhood dental health through community health services and programs like Head Start. The Office of Minority Health plans to offer cultural competency training modules for dental health professionals, which will be available online. (The National Center for Research Resources will also provide Web-based tools for researchers.) And the Centers for Disease Control and Prevention plans to keep track of the overall state of oral health in the United States over the next few years, including the pervasiveness of oral diseases and patterns in dental health behavior. The Centers for Medicare and Medicaid Services, the Office of Women’s Health, and the Health Resources and Services Administration round out the team of collaborators, and each has their own contribution to the initiative.
The foundation of the effort is education, and program coordinators believe that by educating the masses regarding the importance of good oral hygiene and establishing healthy habits at a young age, they can stem the prevalence of tooth decay and oral diseases.
During the 2011 National Nurses Week, a week the American Nurses Association honors every year from National Nurses Day, May 6, to Florence Nightingale’s birthday, May 11, four nursing students were given the opportunity to travel to Sierra Leone to work on a field mission for Mercy Ships.
Since 1978, Mercy Ships has delivered free health care and services to more than 70 countries in the developing world—taking their facilities and staff with them across the oceans on ships. The field mission welcomed four nursing students from Northwest University to prepare in Sierra Leone for the arrival of the largest non-government hospital ship in the world, with a crew of 450, the Africa Mercy.
From their campus near Seattle, Washington, the four students and their professor joined a team of 350 nurses from more than 40 countries who volunteer with Mercy Ships every year. Because Mercy Ships requires volunteer nurses to be registered nurses with at least two years of professional experience, the nursing students prepared on land for the ship’s arrival by gathering medical records for patients and testing day-workers from the local community, who volunteer on the ship, for tuberculosis. One future nurse says she left with an appreciation for the availability of health care in the United States; many of the people they helped in Sierra Leone do not have any hospitals nearby.
Mercy Ships has over 1,200 volunteers every year from a variety of professions, such as surgeons, dentists, cooks, and teachers. While surgical nurses volunteer for two weeks, patient care nurses can volunteer for eight weeks or longer. Students gained perspectives not normally absorbed from classroom lectures or even technical training.