American Academy of Ambulatory Care Nursing Position Paper: The Role of the Registered Nurse In Ambulatory Care Purpose • RNs are fully accountable in all ambulatory care XPLOSIVE CHANGES are occurring in the delivery settings for all nursing services and associated of health services in ambulatory care settings. patient outcomes provided under their direction These changes, fueled by federal legislation, (AAACN, 2011a). national reports about quality and safety, and These statements hold major significance for E ambulatory health care systems and organizations; consistently rising costs (Swan & Haas, 2011), chal- lenge registered nurses to step forward and take a lead nurses and the nursing profession; health care profes- position in bringing health care reform to ambulatory sionals; consumers; regulatory agencies; and federal, care, also known as outpatient, environments state, and local governments. Registered nurses will (Institute of Medicine [IOM], 2011). partner with other health professionals to lead the The American Academy of Ambulatory Care transformation of American ambulatory care systems Nursing (AAACN) is the unifying professional organ- from a traditional medical model to a team-based sys- ization for registered nurses in diverse types of ambu- tem that advances a health care delivery model latory care settings. AAACN is committed to improv- focused on preventing illness, disease, and unneces- ing the quality of health care in outpatient settings, sary complications; promoting wellness; and elimi- enhancing patient outcomes, and realizing greater nating unnecessary costs. health care efficiencies. The purpose of this paper is History of Health Services in Ambulatory Settings: to articulate the essential role of the registered nurse Evolutionary Journey (RN) in achieving these goals. RNs are critical to improving quality and safety and reducing costs in Historically, in outpatient office settings, an indi- ambulatory health care systems. vidual physician or group of physicians examined patients, provided prescriptive medications, and per- Statement of AAACN’s Position formed uncomplicated treatments that did not require It is the position of the American Academy of hospitalization. Patients were referred to other servic- Ambulatory Care Nursing that: es or levels of care when indicated. Unlicensed assis- • RNs enhance patient safety and the quality and tive personnel working directly with physicians per- effectiveness of care delivery and are thus essen- formed the majority of patient care tasks in the clinic tial and irreplaceable in the provision of patient and/or office settings. This often led to unlicensed care services in the ambulatory setting. assistive personnel performing activities commonly • RNs are responsible for the design, administra- associated with professional nursing practice. RNs tion, and evaluation of professional nursing serv- were few, as providers saw little need for profession- ices within an organization in accordance with al nursing services (Mastal, 2010). the framework established by state nurse practice Fiscal caps for hospital care and technological acts, nursing scope of practice, and organizational advances in the 1980s and 1990s propelled a shift of standards of care. health services from the hospital setting to ambulato- • RNs provide the leadership necessary for collabo- ry care settings. In addition to outpatient offices, ration and coordination of services, which diverse types of new ambulatory care settings includes defining the appropriate skill mix and emerged, such as ambulatory surgery centers, infu- delegation of tasks among licensed and unli- sion centers, and diagnostic centers. In these new set- censed health care workers. tings, patients had more acute and complex needs requiring supervision by professional registered nurs- AMERICAN ACADEMY OF AMBULATORY CARE NURSING TASK es to ensure safe, quality care. FORCE MEMBERS: Margaret Fisk Mastal, PhD, RN, Chair; Mary Increased patient complexity requires different Vinson, DNP, RN-BC, CMPE, Board Liaison; Mary Anne Bord- types and higher levels of professional nursing care Hoffman, MN, RN-BC; Catherine Futch, MN, RN, FACHE, NEA-BC, than those provided in the former, traditional outpa- CHC; Linda Harden, MS, BSN, RN-BC; Anne Jessie, MSN, RN; June Levine, MSN, RN; Shirley M. Morrison, PhD, RN-BC, OCN; Valerie tient offices. Ambulatory health care has transitioned Noel, MSN, RN; Carol Rutenberg, MNSc, RN-BC, C-TNP. from a physician-driven system to one that is patient centered, requiring the active participation of multiple ACKNOWLEDGMENT: The American Academy of Ambulatory Care health care professionals who provide both treatment Nursing acknowledge the help of Mary Elizabeth Greenberg, PhD, RN-BC, C-TNP; E. Mary Johnson, BSN, RN-BC; and Joan Pate, MS, for patients and leadership for health care systems. RN-BC, for their review of this position statement. American Academy of Ambulatory Care Nursing — Copyright © 2012 1 Ambulatory Care: Current State safety concerns and successes. In addition, many of The current advances in patient care and techno- the managerial and staff registered nurses are already logical complexity are a result of a confluence of participating in and expanding their roles on the increased patient acuity, evolving practice models, an organizations’ treatment and leadership teams to increase in ambulatory care regulation, and new pro- energize their ambulatory care systems. As these fessional roles. The ambulatory care environment has activities evolve, they advance the quality of care and experienced significant growth in the numbers of services, improve patient outcomes, and enhance patients presenting with acute illness, chronic dis- organizational efficiencies. ease, and/or disabilities (Stokowski, 2011). In 2007, AAACN also conducted an online survey of there were an estimated 994.3 million outpatient vis- members and their professional colleagues. The 464 its made to physician offices (Hsiao, Cherry, Beatty, & registered nurses who responded clearly identified Rechsteiner, 2010), up from 906 million visits in 2003 professional nursing activities that add the greatest (Swan, Conway-Phillips, & Griffin, 2006). Fifty-eight value to patient care in ambulatory settings. These percent of the 2007 visits were to primary care activities include critical thinking, patient and family providers (Internal Medicine, Family Practice, education, advocacy, and care coordination in clinic Pediatrics, and Obstetrics and Gynecology). Primary settings and via telecommunication technology care is the cornerstone of ambulatory health services (AAACN, 2012b). (Hsiao et al., 2010). Ambulatory Care: Nursing Challenges Care models in today’s ambulatory environment are constantly evolving toward team relationships Ambulatory settings employ 25% of the regis- between licensed professionals and unlicensed per- tered nurses in the United States and 33% of the reg- sonnel. Patients are receiving innovative health serv- istered nurses with master’s or higher degrees (DHHS, ices, such as care coordination and referral to internal 2010). While the numbers of registered nurses and and external health care resources. Patients also licensed practical/vocational nurses in ambulatory receive assistance with transitioning between differ- care have increased steadily, there remains significant ent types of services and levels of acuity, as well as confusion regarding appropriate roles for both support in navigating the health care system. In addi- licensed and unlicensed caregivers (AAACN, 2011a). tion, there has been a shift in focus from curing illness Regulatory standards require designated elements to promoting wellness and reducing unnecessary of professional assessment, diagnosis, care planning, costs (Mastal, 2006; Palsbo & Mastal, 2006). and intervention at each ambulatory encounter. Government and private sector regulatory agen- Complex care often requires significant education, cies and quality improvement organizations set stan- care coordination, and clinical management that are dards governing the delivery of ambulatory health best provided by professional registered nurses. care services and outcomes. Accreditation by agen- Additionally, invasive procedures performed in out- cies such as The Joint Commission (2012), the patient settings require ongoing assessment and eval- National Committee on Quality Assurance (NCQA) uation to ensure optimal patient outcomes. RNs are (2011), or the National Quality Forum (NQF) (2012) essential in delivering this care. has become the gold standard for health care systems. Further, telehealth nursing services are an In many organizations it is predominantly registered increasing presence in ambulatory care. These servic- nurses who implement, monitor, and sustain the es bridge and supplement ambulatory care encoun- quality measures associated with accreditation and ters. Telehealth nursing services assist patients in regulatory requirements. making informed decisions regarding access to care, Telephone interviews with nurse leaders and monitor patients’ conditions, and manage care for experts in ambulatory care nursing practice, conduct- both acute and chronic illnesses. This care is provid- ed by AAACN, revealed that in selected organizations ed using telephone, computer, and other forms of registered nurses have positively impacted quality of health surveillance technologies (Park, 2006; Wilson care, patient safety, and patient satisfaction (AAACN, & Hubert, 2002; Wong, Wong, &