Ambulatory Care Nursing: Yes, It's a Specialty

Laura A. Stokowski, RN, MS

Disclosures

September 26, 2011

In This Article

Opportunities in Ambulatory Care

Change is in the air for ambulatory nursing. The Affordable Care Act (ACA) will ensure access to health insurance for as many as 40 million currently uninsured Americans, and these patients are expected to flood the healthcare system, especially ambulatory care settings. The ACA also emphasizes primary care and prevention, 2 pillars of ambulatory care, along with the medical home model of care delivery. These changes will increase the demand for ambulatory care services and increase patient volume in existing practices. Nurses will be needed for newer ambulatory roles such as care coordination, chronic disease management, and telehealth.

Fortunately, ambulatory care registered nurses (RNs) possess the unique skills that will be required in the new healthcare landscape. Ambulatory care RNs can facilitate patient care services by managing and individualizing care for patients and their families, who increasingly require assistance navigating the intricacies of the healthcare system.[1] In addition to the provision of complex procedural care, ambulatory care nurses provide support with decision-making, patient education, and coordination of services.[1]

The bottom line is that ambulatory care nurses will be in great demand, and as hospitals hire fewer nurses, those who are looking for jobs will increasingly look to ambulatory care settings to secure positions. However, many nurses don't have a grasp of what ambulatory care really means. Many think that it is an "easy" job, one that the nurse can simply "coast through" without too much training or effort. Ambulatory nursing might also be viewed as someplace to work until a hospital job comes along, but rarely -- until recently -- has it been viewed as a viable, intentional, career choice. I had the opportunity to speak with June Levine, RN, MSN, a national consultant in ambulatory nursing with Kaiser Permanente, Pasadena, California, to set the record straight about ambulatory care nursing.

Medscape: How does ambulatory care nursing differ from traditional, hospital-based nursing?

June Levine, RN, MSN: In a typical hospital setting, nurses work on specific units with a large team of colleagues including nurse managers, charge nurses, and supervisors. Patients are seen continuously, every day until they are well enough to be discharged or transferred, and although some patients return to the hospital, the nurse-patient relationship ends when patients leave the hospital. Nurses can control the environment and what happens to patients, and interactions with patients are face to face. Nurses can assess their patients with the full range of sensory skills: visual, auditory, olfactory, and tactile. Numerous colleagues are available at all times for support, consultation, and mentoring.

In ambulatory care, patient flow is very different from the hospital. Most patients are seen episodically for as little as 15 minutes at a time. Acute and chronic concerns, preventive assessments, and interventions must all be accomplished in that brief duration of time. It is not the nurses but the patients and families who are in control of patient care. Patients in ambulatory care predominantly engage in self-care and self-managed health activities or receive care from family members. Instead of chiefly providing direct care, ambulatory care nurses teach and guide patients in self-care activities and in helping patients making informed decisions about health behaviors.

An ambulatory care nurse might be working in isolation as the only RN or with few other nurse colleagues, and often without a nursing manager, supervisor, or director. Although ambulatory nursing can involve direct patient care, an ambulatory care nurse is often more the organizer and manager of care rather than the direct provider of care. This type of working environment requires a strong clinical background, leadership skills, and autonomous critical thinking ability that is very different from that employed in acute care. Ambulatory nurses interact with patients not only face to face but over the telephone and computer as well. In the absence of direct sensory input, very different assessment and communication skills are needed.

Medscape: In what types of roles and healthcare settings do ambulatory nurses practice?

Ms. Levine: Ambulatory nurses work in a variety of settings: primary care and specialty outpatient clinics, call centers, freestanding health clinics, nurse-managed clinics, ambulatory surgery centers, patients' homes, and telehealth service environments. The responsibilities, working environment, resources, and degree of independence vary considerably between these different ambulatory settings.

As patients live longer with chronic diseases, complications, and comorbidities, patient care is shifting to the outpatient setting, bringing sicker patients into the ambulatory care arena. The need for more and better prepared RNs has never been greater. As a result of these changes, RNs have more opportunities for a variety of roles in a broad array of settings. Two roles that are relatively new and growing in demand are chronic disease management and telehealth.

Chronic disease management. Effective chronic disease management relies on effective use of community resources, patient self-management, family involvement, and the organization of a healthcare practice designed to focus on this system of care delivery. Chronic disease management requires a clear understanding of the natural course of a disease in a population and the effect of interventions at critical points in time to delay or prevent morbidity and mortality. Care can occur over the telephone and/or face to face, and must include aggressive prevention of complications as well as treatment of chronic conditions. As coordinators of care for patients with chronic diseases, the RN is typically part of a team that includes physicians, advance practice nurses, and others.

Telehealth nursing. Telehealth nursing, considered a subspecialty of ambulatory care, is the delivery, management, and coordination of care and services provided through a telecommunication technology within the domain of nursing. It encompasses all types of nursing care and services delivered across distances to remove time and distance barriers for the delivery of nursing care. Telehealth RNs might work for hospitals, ambulatory practices, or managed care organizations. They might work in a call center, small office, or at home.

Medscape: Most nurses who are looking for nursing positions want hospital jobs. What are the common misunderstandings about ambulatory nursing that might discourage qualified nurses from seeking these positions?

Ms. Levine: Nurses who move from a hospital environment to ambulatory care often expect to use the same knowledge and skills that they used in acute hospital care. However, differences exist in the way that care is organized and the specific skills needed, such as triaging patients both face to face and over the telephone, following up on patient messages, delegating more extensively, and managing emergencies with an entirely different level of equipment and resources to which the nurse is accustomed. In primary care, in particular, effective practice depends on skillful rapid assessment. These days, patients are presenting to their primary care providers with symptoms of heart attack, anaphylaxis, or stroke. Recognizing and responding appropriately to these situations can be lifesaving.

Describing the myths and truths about ambulatory nursing may elucidate the common misunderstandings about this nursing specialty.

Myth #1: Working in ambulatory care does not require specialized nursing skills or judgment because most of the practice is dictated by protocols, guidelines, or algorithms.

Protocols, guidelines, and algorithms are a part of nursing in both inpatient and outpatient settings. Evidence-based medicine and nursing have changed practice as have the Joint Commission, the Centers for Medicare & Medicaid Services, and other organizations that have established standards that must be followed. However, individual judgment must be a part of every nurse's practice, on the basis of the evidence and standards of care.

Myth #2: Ambulatory care is less demanding and not as challenging or stimulating as other areas of nursing practice.

Spending a day with an ambulatory nurse would change this perception. The environment is unpredictable; patient needs are often unknown when they enter the clinical setting; patients often need extensive teaching and community referrals to help them stay out of the hospital; and the role of the nurse from coordinator to practitioner can change frequently throughout the day. Moreover, one might be the only nurse in some clinical ambulatory settings and have no immediate ability to consult with nurse colleagues for a second opinion or assistance with a difficult situation.

Myth #3: Nurses in ambulatory care have limited opportunities for professional growth.

Caring for more and more patients with chronic diseases, being responsible for face-to-face and telephone triage, being knowledgeable in multiple patient education areas, being aware of follow-up needs, supervising unlicensed personnel, and often running the general operation of the clinic are demanding, challenging and stimulating duties. These activities require critical thinking, sound clinical judgment, and strong communication skills. It may be different from working in an inpatient area, but ambulatory nursing does not lack opportunities for leadership and professional growth.

Medscape: What are the prerequisites for becoming an ambulatory care nurse? Can new graduate nurses move directly into this role?

Ms. Levine: Historically, new RN graduates were not able to obtain jobs in ambulatory care. Typically, 1-2 years of nursing practice were required. Additionally, if the RN wanted to practice in a highly specialized area such as the outpatient infusion center, experience in oncology nursing was often required. This is slowly changing. In some ambulatory practices, new RN graduates are being considered for hire.

This transition is similar to the relatively recent change in hiring new RN graduates into critical care or labor and delivery. Regardless of specialty area, the key is the recognition that new RN graduates need a residency program. Transition into RN practice, no matter the specialty, has been documented as a "reality shock" for new graduates. Without a supportive environment to facilitate the growth and development of RNs, many new graduates will leave their first jobs within a year. In fact, the Institute of Medicine report on the Future of Nursing, issued in October 2010, states very clearly in its recommendations that not only do new graduates require a residency program, but so do RNs moving into a new nursing specialty. A residency program can ensure a successful transition into a new specialty such as ambulatory care.

I recently created and implemented a residency program in ambulatory nursing at Kaiser Permanente. For new graduate nurses, the residency lasts a full year, and for experienced nurses transitioning from acute care to ambulatory care, it is a 6-month program. The first part of the program (6 months for new graduates and 4 months for experienced nurses) is devoted to classroom and clinical education about ambulatory care. Residents learn everything from situational awareness and critical thinking to how to have challenging conversations with patients. During the remaining months of residency, new nurses work in their chosen area of ambulatory nursing and continue to have regular contact with preceptors to learn about the specialty of ambulatory nursing.

Medscape: What was the orientation to ambulatory care like before you started a residency program?

Ms. Levine: Before the residency program was implemented, nurses who were new to ambulatory nursing roles would have a very limited orientation -- a few days of facility mandated training and a few more of shadowing a staff member, who might not even be an RN. Not only was this insufficient, but nurses received no real foundation in ambulatory care nursing. It was no wonder that the rate of "going back" to hospital nursing was quite high. Anecdotal data from exit interviews reveal that these new nurses did not leave because they missed acute care, but because they were not well integrated into the ambulatory care setting. It can be difficult, particularly for expert-level nurses to return to the role of advanced beginners. Without a thoughtful transition strategy and visible support, nurses often didn't stick with ambulatory care nursing long enough to appreciate its rich diversity.

Medscape: What considerations might tempt a nurse to seek a job in ambulatory care? We often hear that the jobs are hard to find, and the pay is lower, but the hours are good.

Ms. Levine: It's true that in the past, ambulatory care nursing positions were more difficult to find, primarily because RNs weren't used as much in some of these settings. However, with the development of new roles in healthcare, such as chronic disease management, and the increase in procedural care taking place outside of the hospital, such as in infusion centers and ambulatory surgery settings, opportunities are growing for RNs in ambulatory care. Many of the more traditional ambulatory settings such as primary care are beginning to hire more RNs in preference to medical assistants.

With respect to pay, this depends on where the nurse works. Some settings such as a physician's office might indeed pay less than a local hospital. However, ambulatory settings affiliated with hospitals often pay all nurses in the organization at the same level.

It is somewhat a myth that all ambulatory nurses work "bankers' hours": 9-5; Monday through Friday; with no nights, weekends, or holidays. Although some settings might follow these hours, many others do not, such as call centers or clinics that are open on weekends.

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