Catalyzing Transformation and Ambulatory Care Nurse Action For The Future of Nursing - ProQuest

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Catalyzing Transformation and Ambulatory Care Nurse Action

for the Future of Nursing
Mertens, Kathy; Grayem, Kristene K; Martinez, Kathleen; Mattar, Kelly; Zambrano, Jenelle M; et al. Nursing
Economics; Pitman Vol. 41, Iss. 1, (Jan/Feb 2023): 40-46.
k  9  
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Abstract/Details
Abstract
The "Future of Nursing Report 2020-2030: Charting a Path to Achieve Health Equity" presents an overarching
framework for advancing health equity over the next decade. Given their knowledge and experience,
ambulatory care nurses informed the report development; however, they must embrace opportunities for
further action. Examples of ambulatory care nurses' innovative work and practice are showcased as they
lead efforts across diverse settings with multiple partners. Ambulatory care nurses have the expertise, tools,
and leadership for decisive action. They must continue to activate other nurses, their organizations, and
collaborators to achieve the report's vision.
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Headnote
The "Future of Nursing Report 2020-2030: Charting a Path to Achieve Health Equity" presents an overarching
framework for advancing health equity over the next decade. Given their knowledge and experience,
ambulatory care nurses informed the report development; however, they must embrace opportunities for
further action. Examples of ambulatory care nurses' innovative work and practice are showcased as they
https://www.proquest.com/docview/2776707118?parentSessionId=QRvaPFwTU2bXALOxHg2UjxeLxKo%2BXMu%2BwcMeer1SNv4%3D&pq-origsite=summon… 1/10
lead efforts across diverse settings with multiple partners. Ambulatory care nurses have the expertise, tools,
and leadership for decisive action. They must continue to activate other nurses, their organizations, and
collaborators to achieve the report's vision.
In a dynamic, disruptive, and challenging health care environment, the National Academy for Sciences,
Engineering and Medicine (nAseM) (2021) released The Future of Nursing2020-2030: Charting a Path to
Achieve Health Equity. The report culminated in a study that included commissioned papers, three town
halls across the country, and public comments. It highlighted the acceleration of trends already underway
illuminated by the COVID-19 pandemic. These included the influence of social factors on health status and
disparities, and the pandemic's toll on nurse staffing and well-being.
The landmark report The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine, 2011)
galvanized action. It was published following the Patient Protection and Affordable Care Act of 2010. Nurses
were challenged to lead health care transformation by practicing to the full extent of their education and
training, achieving higher levels of education, becoming full partners in redesigning health care, and
collecting better data for workforce planning and policymaking. Soon after the Future of Nursing (FON)
publication, the Robert Wood Johnson Foundation (RWJF) and the American Association of Retired Persons
(AARP) established the Future of Nursing: Campaign for Action that mobilized coalitions at national and
state levels toward achieving FON recommendations (NASEM, 2016). The follow-up report assessing
progress reported improvement, yet continued progress was needed (NASEM, 2016).
Efforts thrived in a trajectory from the initial 2011 report to the current report of 2021. This article briefly
summarizes the 2021 FON report recommendations, describes ambulatory care nurse expertise that
informed the report development, and highlights ambulatory care exemplars, resources, activities, and
partnerships. These efforts are critical and must catalyze further action to achieve health equity.
FON Development and Ambulatory Care Nursing Involvement
Building on the success of earlier initiatives, the FON 2020-2030 study identified five key areas for
strengthening nursing to address equity of health and health care. These areas included workforce,
leadership, education, well-being, and emergency preparedness/response (NASEM, 2021). The report's
central goal is an achievement of health equity in the United States built upon strengthening nursing
capacity and expertise, including that of ambulatory care nurses.
As the specialty nursing organization for ambulatory care nurses, the American Academy of Ambulatory
Care Nursing (AAACN) presented at the Philadelphia 2019 FON Town Hall on payment and care coordination
for complex health and social needs. The AAACN president addressed the FON Committee and noted
ambulatory care nursing is the future of nursing. At the August 2019 Seattle Town Hall on High Tech to High
Touch, AAACN's immediate past president advocated for technology integration, data standards and
collection, and population-based approaches. AAACN provided the FON Committee with key documents on
the ambulatory care nurse's role, standards, and solutions toward achieving health equity.
AAACN has been visionary and focused on ambulatory care nursing practice to lead this change.
Professional evidence-based foundations of ambulatory care nursing practice developed and disseminated
over the last 10 years include:
* Defining the scope and standards of practice for the ambulatory care registered nurse (RN) (Murray, 2017),
the role of the RN in care coordination and transition management (CCTM), and telehealth.
* Developing a framework, competencies, and education for CCTM (Haas et al., 2019), telehealth, and
ambulatory care nursing (Laughlin & Witwer, 2019).
* Producing numerous position statements, scope of practice standards, core curriculum resources, and
ambulatory care nurse-sensitive indicator references.
Others realize the increasing volume of care delivered in the ambulatory care space (American Hospital
Association, 2021). As health care continues to move from inpatient to outpatient, and payment models shift
from volume-based to valuebased, AAACN has greater opportunities to increase partnerships with
traditionally more inpatient-focused organizations. Ambulatory care nursing leaders must collaborate with
national nursing and health care leaders and policy makers to strategize on inclusion and integration of the
principles of ambulatory care nursing practice in care management across the care continuum. Now is the
time for AAACN, health care organizations, and ambulatory care nurses to build strategic partnerships to
move forward with its mission of advancing the art and science of ambulatory care nursing.
Overview of FON 2020-2030
Recommendations
The FON provides individual and system level recommendations for nurses and those beyond nursing who
can make an impact. Specifically, it constitutes:
...a call for action... including nurses in all settings and at all levels, to listen, engage, deeply examine
practices, collect evidence, and act to move the country toward greater health equity for all.
Recommendations also are targeted to the actions required of policymakers, educators, health care system
leaders, and payers to enable these crucial changes. (NASEM, 2021, p. 12)
The report contains nine overarching recommendations and 54 related action items. Recommendations with
related descriptors are displayed in Table 1.
Exemplars from Ambulatory Care Nurses and Their Organizations
The message of the FON 2020-2030 report resonates with opportunities to improve the health and well-
being of millions of Americans. Ambulatory care nursing takes place where life is lived, across the lifespan,
not within a single episode of care. Many tenets and beliefs of the specialty are prioritized and amplified in
the FON report and confirm the importance of the work of individual ambulatory care nurses, their
organizations, and the individuals they serve and support.
At the 2022 AAACN Annual Conference, nine organizations presented exemplars based on one of the
recommendations that showcased the work of ambulatory care nursing toward achieving the FON report
vision. The FON recommendation, the corresponding exemplar topic, and the organization that spearheaded
the efforts are summarized in Table 2. Some exemplars may support more than one FON recommendation,
such as using technology. The efforts and organizations are diverse and represent actions at both individual
and system levels.
Creating a Shared Agenda
Ambulatory Care Nursing Specialty Organization Develops and Shares Expertise and Resources
The first FON recommendation is "Creating a shared agenda to ensure that all nurses . are prepared,
supported, and empowered to address SDOH and eliminate inequities in health and health care" (NASEM,
2021, p. 357). Much of the work of AAACN members, taskforces, presentations, and publications focus on
exemplars of these topics. In the AAACN (2017) position paper, Role of the RN in Ambulatory Care, AAACN
identified social determinants, environmental factors, and access to care as issues central to the
ambulatory care delivery environment. It determined the RN is accountable for promoting optimal health of
diverse and complex populations, while controlling costs.
AAACN has partnered with organizations, such as the American Nurses Association as an affiliate, to share
information and find solutions to issues facing the nursing profession. Through the AAACN academic-
practice partnership, AAACN members are engaging educators, scientists, and researchers in creating new
models of educating nurses. A Nurse Executive Taskforce provided mentorship, support, and specific tools
to move these models into practice. All of these changes require champi- ons and leaders in positions of
influence to create the vision and secure funding and resources necessary for successful implementation
and outcomes. These leaders are prepared to share knowledge and expertise with other nursing colleagues
to ensure every citizen has access to high-quality, compassionate care.
Supporting Nurses to Advance Health Equity
Remote Nursing Hypertension Optimization Management and Engagement (RNHOME) Program
The Los Angeles County Department of Health Services Population Health Management's Remote Nursing
Hypertension Optimization Management and Engagement (RN HOME) Program aims to help patients with
uncontrolled hypertension achieve blood pressure (BP) control. Patients are referred by their primary care
provider, screened and assessed by the program RN, then enrolled per guidelines. Using antihypertensive
medication titration standardized procedures, RNs can mine adherence, identify and provide education,
titrate antihypertensive medication, and tailor care to help the patient reach their BP goal. RNs actively work
to facilitate patient-centric use of telehealth technology, meeting patients where they are, rather than
utilizing a 'one-size-fits-all approach' to improve the management of uncontrolled hypertension.
Approximately 75% of patients enrolled in the program achieved their BP goal.
Promoting Nurses' Health and Well-Being
Barcode Scanning in Ambulatory Care: Decreases Errors, Saves Time, Increases Staff Satisfaction
South Shore Medical Center (SSMC) is a large ambulatory practice that administers between 6,000 and
13,000 vaccines monthly. From auditing, nurse leaders found the error rate was increasing. As a result, they
developed an interdisciplinary vaccine taskforce. The most impactful intervention was bar code scanning for
vaccine administration. SSMC began using scanners in August 2021. Taskforce members wanted to show
nurses that using barcode scanners would be a time saver. They had end users test the process using
scanners versus entering the vaccine by hand into the electronic health record (Epic). Scanning saved an
average of 30 seconds per vaccine. The timesaving was a huge staff satisfier. Most importantly, the vaccine
error rate decreased to zero from August 2021 to March 2022. Implementing taskforce recommendations
enabled nurses to provide highquality care safely and effectively.
Capitalizing on Nurses' Potential
Veterans Health Administration (VHA) and Defense Health Agency (DHA) Partner to Develop and Implement
Protocol Bundles in Ambulatory Care
For nurses to practice to their full extent of education and abilities, the Veterans Health Administration
(VHA) is partnering with the Defense Health Agency (DHA) to develop and implement standardized,
evidence-based protocol bundles for chronic disease management and acute symptom management in
ambulatory care. The protocol bundles consist of branching logic that aligns with industry standards and
agency performance measures, nurse training, and competency validation tools. The step-wise
implementation plan includes a multidisciplinary team, the use of the ADKAR® Model (Proski, Inc., n.d.) to
promote effective change management, pilot testing, evaluation, and monitoring. ADKAR represents five
outcomes individuals must achieve for successful change: Awareness, Desire, Knowledge, Ability and
Reinforcement.
Paying for Nursing Care
Federally Qualified Health Centers (FQHCs) Leverage Nursing Revenue Opportunities
In the state of Connecticut, RNs at federally qualified health centers (FQHCs) can bill 99211 level services.
For Community Health Center, Inc., a statewide FQHC, this includes nurse visits both by standing and
delegated orders. Delegated provider visits could include performing blood pressure re-checks on specific
patients with hypertension, where nurses follow the provider's patient-specific orders for medication titration
based on the nursing assessment; send an order for a self-managed blood pressure cuff; deliver
comprehensive education regarding diet, exercise, or smoking cessation; and work with patients to set
culturally appropriate self-management goals. Examples of nursing visits by standing orders include those
for acute situations, such as uncomplicated treatment of urinary tract infections and vulvovaginal
candidiasis, COVID-19 evaluations, and for chronic disease management, such as for asthma, hypertension,
diabetes, hepatitis C, and opioid use disorder. Nurses also generate nursing revenue through the population
health department, where nurses complete chart reviews for managed care groups, close specific value-
based care gaps, and perform annual wellness visits with the Medicare population, among other activities.
Using Technology to Integrate Data on Social Determinants of Health into Nursing Practice
Electronic Health Record Tool Enhances RNs Ability to Integrate Social Determinants of Health (SDOH) Data
from Outside Sources into Nursing Practice
Rush University Medical Center's ambulatory care nurses use electronic health record technology (Care
Everywhere in Epic) to integrate social determinants of health (SDOH) data from outside sources, such as
external visit notes, results, and other pertinent health information, into the organization's medical record.
RNs and other providers can then better understand the patient's current health status, living situation, and
economic and social status, facilitating and improving care for the patient. Given the impact on nursing
practice, nurses recommend all medical record systems develop and implement a uniform data model that
also includes the patient's SDOH data.
Strengthening Nursing Education
RNs in Western Carolina University's Primary Care Residency and Fellowship Grant Prepare Nurses to Deliver
Value
The American Association of Colleges of Nursing (AACN) (2021) new framework for training nurses, The
Essentials: Core Competencies for Professional Nursing Education, emphasizes the need to prepare nurses
for community-based practice to assume important roles supporting care coordination and care
management. Enhanced understanding of how SDOH impact access to care and client outcomes is a strong
focus of Western Carolina University RNs in the Primary Care Residency/Fellowship program. In this six-
month immersive program, learners are embedded with an academic and practice partner to prepare for
high-level nursing roles in the primary care setting. The program is one of the federally funded projects
through the Health Resources and Services Administration's (HRSA) Nurse Education, Practice, Quality and
Retention (NEPQR) program. More than half of the graduates, including new BSN graduates, are practicing
in primary care.
Preparing Nurses to Respond to Disasters and Public Health Emergencies
Telehealth Emergency Management Reduces Care Disparities
The VHA integrates telehealth capabilities into emergency management processes to help maintain
continuity of care during disasters and emergencies. Telehealth technologies allow access to clinicians that
otherwise may not be available inperson in a disaster area. Through virtual technology, the VHA is able to
meet veteran needs and reduce disparities in care. VHA Disaster Emergency Medical Personnel System
(DEMPS) members include nurses deployed virtually as well as in-person. This aligns with current clinical
practice and expands the support available to impacted facilities. Specially trained telehealth strike teams
are also available to assist in-person with the rapid establishment of telehealth services at a disaster
alternate care site. Nurses must remain prepared to respond, and one practical approach is to update
emergency plans to include telehealth capabilities.
Building the Evidence Base
Clinical Research Nurse(CRN) Implementation in Ambulatory Care
The clinical research nurse (CRN) was recognized in 2016 by AACN as a specialty practice, where CRNs
provide skilled clinical care and collaborate to facilitate protocol implementation. At the National Institutes
of Health (NIH) Clinical Center, the CRN utilizes a plan of care (POC) to communicate identified problems,
share evidence-based nursing interventions, and develop patient goals. Interactions with patients in
ambulatory areas vary in focus and duration. One important role in the ambulatory environment is the
primary CRN, who is consistently assigned patients with specific disease/conditions, thus facilitating an
expertise and knowledgeable patient relationship. A recent change in the electronic medical record further
enhanced the primary CRN role by allowing ambulatory CRNs to develop and contribute to the nursing POC,
thus enhancing care continuity. Ambulatory CRNs often provide the first introduction to the research
environment. A primary CRN can make all the difference in a patient's experience with clinical research,
providing care coordination and an ronment where will know their concerns, interests, and abilities are
valued and shared collaboratively among team members.
Implications and Call to Action
At the AAACN 2022 Annual Conference Town Hall session on the FON 2020-2030 report, approximately 350
in-person and virtual attendees completed poll questions about their familiarity with FON recommendations,
their organization's implementation of tactics, and their top action priorities (Grayem et al., 2022). Of
attendees participating in each poll, only 25% reported reviewing the report or recommendations, and only
37% reported their organization had implemented tactics based on FON recommendations. After learning
more about the report and exemplars, attendees committed most frequently to actions on promoting nurses'
health and well-being (30.3%), capitalizing on nurse's potential (16.7%), supporting nurses to advance health
equity (14.3%), and strengthening nursing education (10.5%).
Conclusion
Repeatedly, key FON reports and multiple publications communicate the power of nurses as the largest
segment of the health care profession, and they are the most trusted by the public year over year (Saad,
2022). The message of the FON 2020-2030 report resonates with opportunities to improve the health and
well-being of communities. Ambulatory care nurses and their professional organization provided compelling
examples of actions they have implemented, efforts underway, and multiple resources. When learning of
report recommendations and exemplars, nurses commit to action. The foundation exists for creating health
care systems that promote quality, patient safety, and health equity through 2030 and beyond. As noted in
the report, "Nurses have the potential to reshape the landscape of health equity over the next decade by
expanding their roles, working in new settings and in new ways, and markedly expanding their efforts to
partner with communities and other sectors" (NASEM, 2021, p. 127). Ambulatory care nurses are ready to
meet the challenge. $
Kathy Mertens, DNP, MN, MPH, RN
Associate Chief Nurse Ambulatory Care and Population Health
Harborview Medical Center
Seattle, WA
Kristene K. Grayem, MSN, APRN, Amb-BC
Executive Director
Akron Children's Health Collaborative
Chief Population Health Officer
Akron Children's Hospital
Akron, OH
Kathleen Martinez, MSN, RN, CIC, CPN
Infection Preventionist
Children's Hospital Colorado
Aurora, CO
Kelly Mattar, MHA, RN, CMSRN
Clinical Professional Development Specialist

Ambulatory Services
South Shore Medical Center
Norwell, MA
Jenelle M. Zambrano, DNP, CNS, RN, CCNS
Assistant Nursing Director of Education
Los Angeles County Department of Health Services
Population Health Management
Los Angeles, CA
Storm Morgan, DBA, MBA, MSN, RN
Associate Director for Ambulatory Care
Veterans Health Administration
National Oftice of Nursing Services
Washington, DC
Natalie Bycenski, MSN, RN
Senior Nurse Manager and Immunization and Infection Control Specialist
Community Health Center, Inc.
Middletown, CT
Laurie Graaff, MBA, MS-ISM, RN
Telehealth Emergency Management Program Manager
US Department of Veterans Affairs
Oftice of Connected Care, Quality and Training Division
Washington, DC
Mary Myers, MSN, RN, PCCN
Service Educator, Medical Surgical Specialties (MSS)
National Institutes of Health (NIH) Clinical Center
Bethesda, MD
Adrian Jonas, BSN, RN
Clinic RN
Appalachian Mountain Community Health Centers
Asheville, NC
Note
The "Perspectives in Ambulatory Care" column makes sense of today's changing ambulatory care market. It
is written by members of the American Academy of Ambulatory Care Nursing (AAACN) and edited by Mary
Jo Vetter, DNP, RN, AGPCNP-BC, FAANP. For more information about AAACN, please visit www.aaacn.org;
email aaacn@aaacn.org; or call (800) AMB-NURS.
References
References
American Academy of Ambulatory Care Nursing (AAACN). (2017). American Academy of Ambulatory Care
Nursing position paper: The role of the registered nurse in ambulatory care. Nursing Economics, 35(1), 39-47.
American Association of Colleges of Nursing (AACN). (2021). The essentials: Care competencies of
professional nursing education. Author. https://www.aacnnursing.org/Portals/
42/AcademicNursing/pdf/Essentials-2021.pdf
American Hospital Association (AHA). (2021). 2022 environmental scan: Implications for the coming year
and beyond. https://www.aha.org/environmentalscan
Grayem, K., Mertens, K., & Hassmiller, S. (2022, May 17-21). Ambulatory care nursing - A force for the future
of nursing [Presented at the AAACN 2022 Conference, Las Vegas, NV, United States].
Haas, S.A., Swan, B.A., & Haynes, T.S. (Eds). (2019). Care tion and management core curriculum (2nd ed.).
American Academy of Ambulatory Care Nursing (AAACN).
Institute of Medicine. (2011). The Future of Nursing: Leading change, advancing health. The National
Academies Press. https://doi. org/10.17226/12956
Laughlin, C.B., & Witwer, S.G. (Eds.). (2019). Core curriculum for ambulatory care nursing (4th ed.). American
Academy of Ambulatory Care Nursing.
Murray, C. (Ed.). (2017). Scope and standards of practice for professional ambulatory care nursing (9th ed.).
American Academy of Ambulatory Care Nursing.
National Academies of Sciences, Engineering, and Medicine. (2016). Assessing progress on the Institute of
Medicine report The Future of Nursing. The National Academies Press. https://doi.org/10.17226/21838
National Academies of Sciences, Engineering, and Medicine (NASEM). (2021). The Future of Nursing 2020-
2030: Charting a path to achieve health equity. The National Academies Press.
https://doi.org/10.17226/25982
Proski, Inc. (n.d.). The Prosci ADKAR Model. https://www.prosci.com/ methodology/adkar
Saad, Lydia. (2022, January 21). Military brass, judges among professions at new image lows. Gallup.
https://news.gallup.com/poll/ 388649/miliary-brass-judges-among-professions-new-imagelows.aspx
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3/23/23, 11:34 PM Catalyzing Transformation and Ambulatory Care Nurse Action for the Future of Nursing - ProQuest

Full Text | Scholarly Journal

Catalyzing Transformation and Ambulatory Care Nurse Action

Download Cite Email Print All

Full text - PDF

FON Development and Ambulatory Care Nursing Involvement

Overview of FON 2020-2030

Exemplars from Ambulatory Care Nurses and Their Organizations

Creating a Shared Agenda

Supporting Nurses to Advance Health Equity

Remote Nursing Hypertension Optimization Management and Engagement (RNHOME) Program

Promoting Nurses' Health and Well-Being

Capitalizing on Nurses' Potential

Paying for Nursing Care

Federally Qualified Health Centers (FQHCs) Leverage Nursing Revenue Opportunities

Strengthening Nursing Education

Preparing Nurses to Respond to Disasters and Public Health Emergencies

Telehealth Emergency Management Reduces Care Disparities

Building the Evidence Base

Clinical Research Nurse(CRN) Implementation in Ambulatory Care

Implications and Call to Action

Kathy Mertens, DNP, MN, MPH, RN

Associate Chief Nurse Ambulatory Care and Population Health

Harborview Medical Center

Kristene K. Grayem, MSN, APRN, Amb-BC

Akron Children's Health Collaborative

Chief Population Health Officer

Akron Children's Hospital

Kathleen Martinez, MSN, RN, CIC, CPN

Children's Hospital Colorado

Kelly Mattar, MHA, RN, CMSRN

Clinical Professional Development Specialist

South Shore Medical Center

Jenelle M. Zambrano, DNP, CNS, RN, CCNS

Assistant Nursing Director of Education

Los Angeles County Department of Health Services

Population Health Management

Storm Morgan, DBA, MBA, MSN, RN

Associate Director for Ambulatory Care

Veterans Health Administration

National Oftice of Nursing Services

Natalie Bycenski, MSN, RN

Senior Nurse Manager and Immunization and Infection Control Specialist

Community Health Center, Inc.

Laurie Graaff, MBA, MS-ISM, RN

Telehealth Emergency Management Program Manager

US Department of Veterans Affairs

Oftice of Connected Care, Quality and Training Division

Mary Myers, MSN, RN, PCCN

Service Educator, Medical Surgical Specialties (MSS)

National Institutes of Health (NIH) Clinical Center

Adrian Jonas, BSN, RN

Appalachian Mountain Community Health Centers

Proski, Inc. (n.d.). The Prosci ADKAR Model. https://www.prosci.com/ methodology/adkar

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