Scope and Standards of Practice for Professional Ambulatory Care Nursing [9 ed.] 9781940325392, 9781940325361

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Edition 2017 - 9th

s d r a d n a t S & Scope r o f e c i t c a r P f o y r o t a l u b m A l a n o i s s Profe g n i s r u Car e N Copyright © 2017 American Academy of Ambulatory Care Nursing (AAACN) East Holly Avenue/Box 56, Pitman, NJ 08071-0056 800-AMB-NURS | FAX 856-589-7463 | [email protected] | www.aaacn.org eISBN: 978-1-940325-39-2 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system without the written permission of the American Academy of Ambulatory Care Nursing. DISCLAIMER The authors, editors, and publishers of this publication have made serious efforts to ensure that practices, procedures, and treatments are accurate and conform to standards accepted at the time of publication. Due to constant changes in information resulting from continuous research and clinical experience, reasonable differences in opinions among authorities, unique aspects of individual clinical situations, and the possibility of human error in preparing such a publication, the reader should exercise individual judgment when making a clinical decision, and if necessary, consult and compare information from other authorities, professionals, or sources. Suggested Citation American Academy of Ambulatory Care Nursing. (2017). Scope and standards of practice for professional ambulatory care nursing (9th ed.). C. Murray (Ed.). Pitman, NJ: Author. Publication Management by Anthony J. Jannetti, Inc., East Holly Avenue/Box 56, Pitman, New Jersey 08071-0056 Phone: 856-256-2300 | Fax: 856-589-7463 | www.ajj.com

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Standards Revision Task Force

Collaborators

Cynthia L. Murray BN, RN-BC, Chair and Editor Ambulatory Care Clinical Nurse Manager Veterans Health Administration (VHA) Veterans Integrated Service Network (VISN) 4 Southern NJ and Delaware Health System

Cynthia Murray, BN, RN-BC Care Coordination and Transition Management Scope & Standards for Professional Nursing Practice Task Force Chair

Nancy Auger Buckman, MSN, MBA, RN Vice President Health Transformation Innovation Team AON Boston, MA Maria Hamakiotis, MSN, RN Nursing and Professional Practice Director Northwestern Medical Group Chicago, IL Trudy A. Laffoon, MA, RN-BC Nurse Manager University of Iowa Hospitals and Clinics, Iowa City, IA Adjunct Faculty Kirkwood Community College Cedar Rapids, IA Anne Marie McLeod, RN, DNPc Stroke Program Coordinator University of Michigan, Comprehensive Stroke Center Student, Doctor of Nursing Practice University of Michigan School of Nursing Ann Arbor, MI Sharon Schmidt, DNP, MSN, BSN, RN Associate Director Clinical Services Yale Health, Yale University New Haven, CT Jude Sell-Gutowski, MSN, RN Senior Director of Nursing Dignity Health Medical Foundation Rancho Cordova, CA David Thomas V, CDR US Navy Okinawa, Japan Susan Trapp, BSN, RN-BC Clinic Manager Nebraska Medicine Family Medicine Bellevue Bellevue, NE Mary Hines Vinson, DNP, RN-BC Associate Chief Nurse, Ambulatory (Retired) Duke University Health System Durham, NC

Advisor Margaret F. Mastal, PhD, MSN, RN AAACN Past President Retired Alexandria, VA

Board Liaison Kristene Grayem, MSN, CNS, PPCNP-BC, RN-BC Director of Clinical Systems and PI Akron Children’s Hospital Akron, OH 2

Susan Paschke, MSN, RN-BC, NEA-BC Registered Nurse Role Position Paper Update Task Force Chair Suzanne N. Wells, MSN, RN Telehealth Update Task Force Chair

Reviewers Amy B. Eilertsen, MN, RN Ambulatory Nursing Practice Lead Dartmouth-Hitchcock Medical Center Lebanon, NH Deena Gilland, MSN, RN, NEA-BC VP of Patient Services and Chief Nursing Officer, Ambulatory Care Emory Healthcare Atlanta, GA Mary Anne Granger, MSN, RN Director, Health Services Division Benchmark Research Technologies Phoenix, AZ Kathryn Koehne, DNP, RN-BC, C-TNP Nurse Educator / Adjunct Faculty Gundersen Health System / Viterbo University La Crosse, WI Mary Koithan, PhD, CNS-BC, FAAN Anne Furrow Professor and Associate Dean Professional and Community Engagement University of Arizona, College of Nursing Tucson, AZ Aleesa Mobley, PhD, RN, APN, CPHQ Adjunct Professor of Nursing Rowan University Glassboro, NJ Susan M. Paschke, MSN, RN-BC, NEA-BC Past President, AAACN Part-Time Faculty Kent State University Kent, OH Assanatu (Sana) I. Savage, PhD, DNP, FNP-BC, RN-C CDR, NC, USN United States Navy Sasebo, Japan Jane W. Swanson, PhD, RN, NEA-BC, FAAN Director, Geri and Richard Brawerman Nursing Institute for Professional Development Cedars-Sinai Medical Center Los Angeles, CA

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Table of Contents Scope and Standards Revision Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Overview of the AAACN Standards 9th Edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Scope of Practice for Professional Ambulatory Care Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 I. Definition of Professional Ambulatory Care Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 II. Conceptual Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 III. Evolution of Modern Ambulatory Care and Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 IV. Practice Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 V. The Science and Art of Ambulatory Care Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 VI. Ambulatory Care Nursing Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 VII. Professional Trends and Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Standards of Practice for Professional Ambulatory Care Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Standards of Professional Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Standard Standard Standard Standard

1: 2: 3: 4:

Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 Outcomes Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Standard 5: Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 5a: Coordination of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 5b: Health Teaching and Health Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 5c: Telehealth Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 5d: Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Standard 6: Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Standards of Nursing Organizational and Professional Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Standard 7: Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 Standard 8: Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 Standard Standard Standard Standard Standard Standard Standard Standard

9: Research and Evidence-Based Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 10: Performance Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 11: Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 12: Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 13: Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 14: Professional Practice Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 15: Resource Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42 16: Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 Additional Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

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Introduction he American Academy of Ambulatory Care Nursing (AAACN) is the specialty nursing organization for nurses practicing in ambulatory care settings. AAACN  is responsible for establishing and maintaining the standards for ambulatory care professional nursing practice. Ambulatory care is defined as outpatient care in which individuals stay less than 24 hours in the health care environment and are then discharged to their residential situation following the care episode. This publication is an updated scope of practice statement and 16 revised standards for the clinical and administrative professional practice of ambulatory care registered nurses (RNs). The standards promote effective clinical and administrative management of increasingly complex ambulatory care RN roles and responsibilities in a changing health care environment. This publication maybe used to: 1. Provide guidance to outpatient care systems for the development of structure and processes in the delivery of ambulatory care nursing (e.g., policies, procedures, role descriptions, and competencies). 2. Guide the delivery of quality nursing care for patients, populations, and communities. 3. Facilitate the development of professional nursing knowledge in ambulatory care. 4. Facilitate the evaluation of professional nursing performance as evidenced in performance appraisals, peer reviews, and reflective practice. 5. Stimulate participation in research and evidence-based practice. 6. Guide performance improvement initiatives in clinical and organizational environments. 7. Guide ethical practice and patient advocacy. 8. Serve as a tool to advance ambulatory care professional nursing practice, patient health states, and the performance outcomes of ambulatory care health care institutions. The scope of practice statement addresses the definition and unique characteristics of ambulatory care nursing, the conceptual framework, its history over the past 30 years, the diverse types of ambulatory care settings, the roles of ambulatory care RNs, the trends and issues in ambulatory care and future directions. The standards specify the competencies needed for professional clinical and administrative practice. Together, the scope and the standards provide a structure for cataloguing and unifying the distinct nurse-patient interactions and organizational activities that occur in diverse ambulatory care environments.

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Overview of the AAACN Standards 9th Edition In 1987, AAACN published the first edition of the standards. That document contained the landmark standards for professional ambulatory care nursing and administration. It outlined, for the first time, a definition, philosophy, and standards reflecting the unique ambulatory care nursing environment. Ambulatory care nursing is dynamic – changing and expanding to meet the health care needs of the populations served, along with the demands of institutions delivering care. Inspired by the visions, values, and traditions of the past, these standards reflect current professional norms, practices, and expectations. The standards recognize the evolving landscape of professional practice by regular review with needed revisions since 1987, ensuring usefulness, relevancy, accuracy, and measurable outcomes. The standards are now in their 9th edition. This set of revisions represents the work of the Scope and Standards of Practice for Professional Nurses Task Force members who conducted a broad scope of activities from September 2015 to December 2016. The task force members searched a broad base of literature for knowledge and evidence and consulted with nurses practicing in diverse organizational settings. Recognized ambulatory care nurse leaders provided additional input through reviews and comments. The 9th edition of the Scope & Standards of Practice for Professional Ambulatory Care Nursing contains some significant revisions from previous versions. In addition to the revised scope of practice, this publication contains 16 standards. The first six address the phases of the nursing process; the last ten standards address professional performance. The depth and breadth to which ambulatory care RNs engage in the total scope of professional ambulatory care nursing practice is dependent upon their education, experience, role, practice setting, and the populations served (American Nurses Association [ANA], 2015). Each standard contains three sections: 1. A statement of the standard addressed. 2. Measurement criteria that may be used for demonstrating competency for meeting the standard. 3. Additional standard statements and measurement criteria for nurse executives, administrators, and managers. These changes offer clarification and specificity for the distinct domains of clinical and administrative nursing practice in ambulatory care settings.

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Scope of Practice for Professional Ambulatory Care Nursing he scope of practice statement describes the “who,” “what,” “where,” “when,” “why,” and “how” of professional ambulatory care nursing practice. It offers a picture of the dynamism and complexity of nursing in outpatient settings and its evolving boundaries (ANA, 2015). The scope of practice initially defines the ambulatory care nursing specialty, its defining characteristics, and presents its conceptual framework. This document also reviews the history of ambulatory care nursing, the events that changed its nature over time, the existing challenges, and the future possibilities.

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I.

Definition of Professional Ambulatory Care Nursing Professional ambulatory care nursing is a complex, multifaceted specialty that encompasses independent and collaborative practice. The comprehensive practice of ambulatory care nursing is one built upon a broad knowledge base of nursing and health sciences, and applies clinical expertise rooted in the nursing process. RNs use evidence-based information across a variety of outpatient health care settings to achieve and ensure patient safety and quality of care while improving patient outcomes (AAACN, 2011). Ambulatory care includes those clinical, organizational, and professional activities engaged in by RNs with and for individuals, groups, and populations who seek assistance with improving health and/or seek care for health-related problems. RNs promote optimal wellness, participate in the management of acute illness, assist the patient to manage the effects of chronic disease and disability, and provide support in end-of-life care. The ambulatory care RN is accountable for the provision of nursing care in accordance with relevant federal requirements, state laws and nurse practice acts, regulatory standards, the standards of professional ambulatory care nursing practice, other relevant professional standards, and organizational policies (AAACN, 2011). Defining Characteristics The following attributes (AAACN, 2011, pp. 6-7) are distinctive to professional RN practice in ambulatory care settings: 1. Ambulatory nursing care requires critical reasoning and astute clinical judgment to expedite appropriate care and treatment, especially given the patient may present with complex problems or potentially life-threatening conditions. 2. Ambulatory care RNs provide quality care across the life span to individuals, families, caregivers, groups, populations, and communities.

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3. Ambulatory care nursing occurs across the continuum of care in a variety of settings, which include but are not limited to: • Hospital-based outpatient clinics/centers. • Solo or group medical practices. • Ambulatory surgery and diagnostic procedure centers. • Telehealth service environments. • University and community hospital clinics. • Military and Veterans Administration settings. • Nurse-managed clinics. • Managed care organizations. • Colleges and educational institutions. • Freestanding community facilities. • Care coordination organizations. • Patients’ homes. 4. Ambulatory care RNs interact with patients during face-to-face encounters or through a variety of telecommunication strategies, often establishing long-term relationships. 5. Telehealth nursing is an integral component of professional ambulatory care nursing that utilizes a variety of telecommunications technologies during encounters to assess, triage, provide nursing consultation, and perform follow up and care coordination. 6. Ambulatory care RNs practicing in telehealth environments adhere to the AAACN Scope and Standards of Practice for Professional Telehealth Nursing (AAACN, in press). 7. During each encounter, the ambulatory care RN focuses on patient safety and the quality of nursing care by applying appropriate nursing interventions, such as identifying and clarifying patient needs, performing procedures, conducting health education, promoting patient advocacy, coordinating nursing and other health services, assisting the patient to navigate the health care system, and evaluating patient outcomes. 8. Nurse-patient encounters in clinical settings can occur once or as a series of occurrences, are usually less than 24 hours in length at any one time, and occur in single or group settings. 9. Ambulatory care RNs, acting as partners, advocates, and advisors, assist and support patients/families in the optimal management of their health care, respecting their culture and values, individual needs, health goals, and treatment preferences. 10. Ambulatory care RNs facilitate continuity of care using the nursing process, interprofessional collaboration, and coordination of and access to appropriate health care services and community resources across the care continuum. 11. Ambulatory care RNs are knowledgeable about and provide leadership in the clinical and managerial operations of the organization.

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12. Ambulatory care RNs design, administer, and evaluate nursing services within the organization in accord with relevant federal requirements, state laws and nurse practice acts, regulatory standards, and institutional policies and procedures. 13. Ambulatory care RNs provide operational accountability for and coordination of nursing services, including the appropriate skill mix and delegation of roles and responsibilities for licensed and unlicensed nursing personnel. 14. Ambulatory care RNs apply the provisions of the ANA Code of Ethics for Nurses to their own professional practice. 15. Ambulatory care RNs pursue lifelong learning, which updates and expands their clinical, organizational, and professional knowledge, skills, and abilities in professional practice. 16. Ambulatory care RNs functioning in care coordination and transition management roles and settings adhere to the AAACN Scope and Standards of Practice for RNs in Care Coordination and Transition Management (AAACN, 2016). Objectives of Ambulatory Care Nursing The major objectives of ambulatory care nursing align with other types of nursing to: • Protect and promote health. • Minimize suffering. • Maximize health literacy and education. • Prevent illness and injury. • Apply nursing interventions to human responses in health, illness, disease, disability, and end-oflife circumstances. • Actively advocate for optimal coordinated health care of individuals, families, communities, and populations aimed at improving the whole person’s well-being. Interactions between patients and ambulatory care nurses to achieve patient goals occur in the context of caring, compassion, and sensitivity to the patient’s cultural, ethnic, and age-related needs. Professional ambulatory care RNs use the nursing process in a variety of settings and roles. The RN performs an assessment of a population, individual, or caregiver’s problems and concerns. The ambulatory care RN analyzes and integrates subjective and objective data, decides on a plan of nursing action, applies the appropriate nursing intervention, and evaluates the outcomes. II. Conceptual Framework The conceptual framework for ambulatory care nursing identifies three major concepts and the links between and among them: patient, environment, and nurse. Patient Inherent within the concept of patient is each individual is unique; functions holistically as a biological, psychosocial, and spiritual being; and is the

center of patient-nurse interactions. Patients in the ambulatory care setting refer to individuals, families, caregivers/support systems, groups, and populations that approach the health system in a variety of circumstances or health states. Patient health states are categorized as wellness or health, acute illness, chronic disease and/or disability, and end of life. Generally, the patient initiates contact with the ambulatory care system to meet his or her wellness concerns and health needs. In many cases, if the patient has a chronic disease/disability or is in an end-of-life phase, the nurse intermittently reaches out and contacts the patient to determine his or her status and needs. Patients are always the central focus and maintain control of the encounter and treatment with the nurse in a consultative role. Environment Environment as a concept helps define ambulatory care nursing practice, setting it apart from other nursing specialties. In addition to unique nursepatient relationships and interactions, ambulatory care nurses also must address organizational, social, economic, legal, and political factors within the health care system and in the external health care environment. The ambulatory care environment has two major dimensions. Internal care delivery environment. The ambulatory nursing care delivery environment is dynamic and diverse – a broad scope of practice in multifaceted settings where patients seek health care treatment and where the professional RN functions. Regardless of the setting, ambulatory encounters are always less than 24 hours. The internal environment also includes vitual encounters using telehealth technologies to provide care across distances. External health care environment. The external environment refers both to the physical location of each health care practice setting as well as to health care contextual factors and health resource agencies across the greater environment that affect ambulatory care practice in unique ways. The external geographical locale, available health care resources, and contextual factors that affect an individual ambulatory health care setting often influence that setting’s mission, patient population, and practices. These external contextual factors include, but are not necessarily limited to: 1. The patient’s living environment. 2. The surrounding community population’s specific needs, perceptions, and resources. 3. The health resources available across the community’s health care continuum to include virtual plateforms. 4. Health policy, governmental laws, professional practice regulations, and accrediting agencies. 5. Health care financing systems. 6. Advances in science and technology (scientific knowledge, diagnostic, treatment, and telehealth technologies).

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Figure 1. Ambulatory Care Nursing Conceptual Framework Diagram External Health Care Environment Community Health Needs, Perceptions, Resources

Advances in Science and Technology

Government Laws

Ambulatory Care Patient

Ambulatory Care Nurse

Health Acute Illness Chronic Disease and/or Disability End-of-Life

Interaction

Clinical Role Systems Role Professional Role

Regulatory and Accrediting Agencies

Internal Care Delivery Environment

Health Care Financial Systems

7. The expanding information management systems that support patient care and document data through electronic information exchange. 8. General circumstances such as socioeconomic factors, cultural considerations, safety, transportation, pollution, disasters, epidemics and/or pandemics, etc. Nurse Professional ambulatory care nursing is a unique domain of specialty nursing practice. It focuses on individuals, families, groups, communities, and populations in primary and specialty care, virtual encounters and non-acute community outpatient settings. The scope of professional ambulatory care nursing is dynamic in response to changing societal, organizational, and technological needs as well as the expanding knowledge base of nursing’s theoretical and scientific domains (ANA, 2003), especially as related to ambulatory care. Ambulatory care RNs practice in three major roles: clinical, organizational and/or systems, and professional. While defined separately, these roles are not necessarily mutually exclusive and frequently overlap. This overlap of roles brings challenges and professional growth, adding dynamism, learning, and diversity to ambulatory care nursing practice. Clinical nursing role. Ambulatory care RNs practice clinically by using the nursing process in their specific specialty role. Clinical nursing in all ambulatory care settings requires expert nursing process skills: assessment of patient problems and concerns in limited periods; the ability to critically analyze and integrate subjective and objective data related to patient concerns and conditions; and 8

General Environmental Circumstances

identification of pertinent problems and goals. The ambulatory care RN is competent in planning appropriate nursing care and can implement suitable evidence-based interventions and evaluate goals effectively. This clinical role also encompasses patient advocacy, referring patients to optimal health services within the organization and across the care continuum, education about health promotion, and prevention of disease and secondary complications. This role also includes performing appropriate nursing procedures, and consulting and collaborating with professional colleagues. The ambulatory care RN will provide accurate and complete documentation of care given, and in general, manage clinical nursing care practice and care outcomes. Inherent in the clinical role is the use of and development of appropriate, evidence-based nursing knowledge and health care protocols. Organizational and/or systems role. When RNs practice within this role, they administer and coordinate resources, and direct clinical and activity workflow within their health care setting. It also includes collaboration with other health care resources and agencies across the care continuum. This role has multiple dimensions: leadership, staffing, workload, and competency concerns; workplace regulatory compliance and risk management; fiscal management; legal and regulatory issues; organizational cultural competence; and application of health informatics systems. It also includes diagnostic and treatment technologies, conflict management, structuring customer-focused systems, and patient and health advocacy within the organization and across the community’s care continuum.

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III. Evolution of Modern Ambulatory Care and Nursing Practice Modern ambulatory care nursing evolved over the 20th century particularly in the last quarter of the century and the evolution has escalated in the early years of the 21st century. It was during the latter half of the 20th century that dramatic changes occurred in the American health care system. Post World War II the focus was on hospital care that led to the relatively unrestrained growth of the health care industry, limited financial risk to the insured patient, and increased professional autonomy. Ultimately, these forces led to major shifts in national health and fiscal policy.

Redefining Health Care Concurrently, health organizations began to redefine health care, especially the World Health Organization (WHO) and the Institute of Medicine (IOM). In 1978, WHO issued a primary care report that describes primary health care as “essential care ... made universally accessible to individuals and families in the community ... through their full participation and at a cost that the community and country could afford” (WHO, 1978, p. 3). In the same year, the IOM (currently known as National Academy of Medicine) issued the first definition of primary care in the United States. The definition includes conceptualizing primary care in terms of personal services rather than public health services, declaring it should be “accessible, comprehensive, coordinated and continual by accountable providers of health services” (WHO, 1978, p. 16). At the turn of the 21st century, the IOM took leadership and addressed issues that would improve health care processes and patient outcomes in a pivotal report, To Err is Human: Building a Safer Healthcare System (Kohn, Corrigan, & Donaldson, 2000). Following that report was a widely cited report, Crossing the Quality Chasm: A New Healthcare System for the 21st Century, that advocated sweeping reform of the entire health care system (IOM, 2001). The landmark report identified nursing as the largest component of the health care workforce and in a key position to improve patient safety and influence the health care system. It highlighted how nurse interactions in the workplace facilitated or hindered patient care and outcomes. One of the recommendations was to support interprofessional collaboration by adopting an interprofessional practice mechanism. In 2008, nursing elements that promote positive patient outcomes – nursing quality indicators, strong nurse manager capabilities, leadership and support, and collegial nurse-physician relations – were identified by Aiken, Clarke, Sloane, Lake, and Cheney.

Drivers of Change Significant changes occurred when major payers (federal, state, and local government agencies and employers) observed increases in health care utilization and soaring costs. Additionally, the public began losing confidence in the health system’s ability to deliver results, assure access, and contain costs. The primary impact of these changes was a shift in where the patient received care (from hospitals to ambulatory care settings), a shift from emphasizing specialty care to primary and preventive care, and the move from fee-for-service reimbursement insurance to capitated payment in a managed care system. There was also a major push to pay for value-based care identified by improving the quality of patient care and health outcomes. Further, governmental and regulatory agencies, rather than providers, play a larger role in setting standards for quality care and health outcomes (Mastal, 2006).

Industry Transformation The health care industry transformation started in the late 1980s. Historically the industry focused on illness and reimbursement on a fee-for-service or transaction basis. Now the industry is population health oriented and reimbursed based on value. Berwick initiative. In the late 1980s, Donald Berwick and other visionary colleagues launched the National Demonstration Project on Quality Improvement in Healthcare. The initiative aimed at “redesigning healthcare into a system without errors, waste, delay, and unsustainable costs” (Institute for Healthcare Improvement, 2017, para. 1). This led to changes in clinical practice that accelerated the pace of transition of care from the acute setting to ambulatory care and community settings. The Institute for Healthcare Improvement (IHI). The IHI, also led by Berwick, was established to realize the vision of the demonstration initiative. The IHI began its work focused on identifying and

Professional role. Ambulatory care RNs function within this role when they practice according to professional, ethical, and organizational standards. It also requires the use of evidence-based intervention, the evaluation of the outcomes of nursing practice, the personal lifelong expansion of ambulatory care nursing knowledge and skills. The professional RN contributes to the knowledge and skills of other staff, and continuous improvement of the quality of health care practices and outcomes. As a practice expectation, professional ambulatory care RNs are to exhibit leadership skills within the health care organization, in the greater community, and across the nursing profession. While some functions of all three roles are part of every ambulatory care RN’s practice, emphasis on one of the roles usually exists depending on the specific functional position of the nurse within the practice setting. For example, when functioning in direct care interventions, nurses will most likely focus largely on the clinical role requirements of their job descriptions. However, organizational and professional role requirements may be expected concurrently depending on the organization’s structure and the unique situation. See Figure 1 for the Ambulatory Care Nursing Conceptual Framework Diagram.

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disseminating best practices. Recognized throughout the world for coining the term “Triple Aim” in 2004, it launched innovative work to optimize health, care experience, and cost (IHI, 2017). Triple Aim initiatives spawned innovation in clinical practice redesign and payment models. Institute of Medicine (IOM). The IOM Committee on the Quality of Healthcare in America published Crossing the Quality Chasm in 2001. The report identified six aims for improvement of patient care: safe, effective, patient-centered, timely, efficient, and equitable. These innovative quality initiatives catalyzed when President Barack Obama signed a federal mandate on March 23, 2010, establishing the Patient Protection and Affordable Care Act (PPACA), more commonly known as the Affordable Care Act. The law was upheld by the Supreme Court on June 28, 2012. The Centers for Medicare & Medicaid Services (CMS) Innovation Center, section 1145 of the Social Security Act, also became a part of the PPACA. Legislative impact. The CMS Innovation Center was commissioned for testing “innovative payment and service delivery models to reduce program expenditures…while preserving or enhancing the quality of care” for those individuals who receive Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) benefits (CMS, 2016, para. 2). In addition, the PPACA contained many provisions for enhancing and incrementally funding team-based primary care and Patient-Centered Medical Homes (Patient-Centered and Primary Care Collaborative, 2017). A demonstration project funded through the Innovation Center tested clinical practices and payment arrangements. These included Pay for Performance, Accountable Care Organizations, Patient-Centered Medical Homes, Bundled Payments, Transitions of Care, and Ambulatory Care Management, all of which include nurses in pivotal roles. RNs, with their holistic training and enduring patient and family advocacy responsibilities, are well positioned to assume clinical and leadership roles in transforming the delivery system (Bailes, Rachel, & Keller, 2014). The evolution of RN roles has kept pace with Innovation Center activities, emphasizing inpatient quality and safety, care coordination that supports transitions of care, engagement in ambulatory care teams, community organizations, and Patient-Centered Medical Homes. Many of the PPACA regulatory measures (Bailes et al., 2014) and CMS quality metrics (CMS, 2017) link nursing roles and responsibilities. Primary Care Emphasis Primary care is essential care, the conceptual foundation for and the cornerstone of ambulatory care health services. Primary care practitioners promote health and wellness, diagnose and treat patient problems, as well as coordinate access to other care levels and settings. They coordinate the 10

use of secondary care levels (e.g., hospitalizations, specialty referrals, advanced diagnostic and therapeutic care) and tertiary care (highly specialized and technological care). As health care evolved in the early 21st century, the number of uninsured Americans increased and emergency department encounters for primary care issues soared, resulting in a higher cost of care (Mastal, Matlock, & Start, 2016). Due to the high volume of individuals who accessed primary care, models of care delivery changed. Sole accountability for care began to transition from individual physician or advanced practice RN (APRN), to delivery by teams. Organizational and professional policies redefined roles and responsibilities within the teams. Telehealth Services Telehealth services emerged first as telephone nursing to manage increased costs and improve access to quality patient-centered care. It became a recognized subspecialty of ambulatory care nursing. As telephone nurses developed professionally, AAACN created and published formal telehealth professional standards. When using the support of telehealth technology, RNs provide patients and caregivers health information, offer timely access to the appropriate health care provider, and function as integral members of the interprofessional health care team. When using telehealth technology, RNs often initiate contact with persons with chronic illness and/or disease to maintain optimal health. In addition, RNs using the telehealth technology communicate changes and updates for the interprofessional health care team. Care Coordination and Transition Management Services Care coordination and transition management (CCTM®), formalized by the PPACA of 2010, required individual written plans of care and followup plans that move with patients over time. CCTM is an innovative patient-centered interprofessional care delivery model. It integrates the RN as care coordinator and transition manager (Haas, Swan, & Haynes, 2014). This new role emerged as professional nursing practice that spans the entire health care continuum. The CCTM role has its own unique Scope and Standards of Practice for Registered Nurses in Care Coordination and Transition Management (AAACN, 2016). IV. Practice Environment Ambulatory care encounters occur in clinic settings, on the telephone, by electronic messaging, or by virtual telehealth encounters. They are generally, although not always, initiated by the individual seeking information and/or care. The practice environment encompasses specific practice settings, usually defined in terms of the medical specialty, and the types of larger institutions in which these settings reside.

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Practice Settings The ambulatory health care system spans primary care (when the patient first seeks care) through acute care, chronic and disability care follow-up, and palliative care in end-of-life situations. Ambulatory care nurses care for patients and populations in all phases of preventive care, health maintenance, diagnosis, treatment, and follow-up as they move in and out of acute care or other settings across the care continuum. Primary care. Primary care is the cornerstone of ambulatory care with nurses practicing in: • Internal medicine • Family practice • Pediatrics • Women’s health clinics (OB/GYN) • Telehealth services RN roles in primary care generally encompass clinical functions, working within organizations and/or systems, and professional functions. With the expansion of ambulatory care, RNs also practice in a variety of diagnostic and specialty clinics. Diagnostic and specialty care. Subspecialties are numerous and diverse in both medical and surgical categories. Ambulatory care RNs practice in all subspecialties, such as: • Medical specialties (allergy, cardiology, endocrinology, gastroenterology, infectious disease, neurology, oncology, psychiatry, etc.) • Oncology infusion centers • Care management organizations • Surgical specialties (general surgery, cardiac surgery, neurosurgery, orthopedics, etc.) • Ambulatory surgery centers • Diagnostic centers (e.g., cardiac, gastroenterology, radiology, and imaging) • Telehealth services Types of Ambulatory Care Organizations Ambulatory care RNs practice in a variety of organizational settings. An organization’s characteristics are defined by its structure, patient population, financial and reimbursement mechanisms, and organization of primary and specialist providers (usually physicians). Within the types of ambulatory care organizations there may also be internal differences based on size, regional location, network or health system affiliation, and regional differences in health finance administration. Major categories of ambulatory care organizational settings include: • University hospital outpatient departments • Community hospital outpatient departments • Solo and group medical practices • Accountable Care Organizations (ACOs) • Telehealth service centers • Health maintenance organization (HMO) clinics and services • Government health systems (federal, state, and local) including military bases

• Community and freestanding centers such as: • Occupational health centers • School/College health centers • Shelters for the homeless • Ambulatory surgery and special procedure centers • Urgent care centers • Care management or care coordination/transition management organizations • Dialysis centers • Infusion centers • Imaging centers The practice environments of ambulatory care RNs are multiple and varied, but serve as the foundation of care in the American health care system. See Figure 2 for the context of ambulatory care nursing practice. Treatment Episodes An episode of care in the ambulatory care environment is an in-person visit, telehealth visit, and/or an electronic message encounter. The treatment is episodic rather than continuous and may include multiple episodes. Opportunity for direct observation of the person can be minimal in nature and time-compressed with the nurse, at least initially, relying largely on patient-reported symptoms. RNs use the nursing process during diagnostic and treatment episodes that are patient centered. In some settings, treatment may be to a specified group or population. Treatment plan. The management of the treatment plan in ambulatory care settings is largely the responsibility of the patient/family system. The ambulatory care RN, as consultant and advocate, pursues a more comprehensive understanding of the patient’s condition. Questioning techniques, such as motivational interviewing, gather additional data to provide information necessary to make critical judgments about diagnosis and care (Case Western Reserve University, 2011). In recent years, ambulatory care organizations have acquired sophisticated health information systems and nurses have access to more objective patient data (Haas & Hastings, 2013). Ambulatory care interventions. Historically, interventions by ambulatory care RNs tended to be patient initiated and focused on health care advice, information on how to manage a condition in the home, or instructions on how to prepare for diagnostic testing. As persons and populations with more complex needs are cared for in outpatient settings, the scope and complexity of RN practice has broadened and increased. This is especially true for patients with comorbidities related to chronic disease and disability (Haas & Hastings, 2013). Today, nurses often proactively assess patient and/or population needs and guide health care delivery, lead nurse-managed clinics, implement nursing-initiated protocols, engage in community outreach, and provide health education, health promotion, and care coordination.

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Figure 2. Context for Ambulatory Care Nursing Practice

Patient Management Strategies Ambulatory Nursing Practice Settings

• Preventive and health maintenance services • Telehealth services

• Primary care services • Telehealth services • Accountable Care Organizations • Retail clinics Patient selfmanagement

Patient seeks care • Emergency and urgent care services • Telehealth services

Specialty care services

• Triage • Assessment • Treatment • Health education • Care coordination

Hospital admission

Long-term care

• Follow-up care and monitoring • Treatment • Health education • Care coordination

Community and home health services

Ambulatory surgery and special procedures

• School health and occupational health services • Telehealth services

Source: Adapted from Hastings, 2013 and AAACN/ANA, 1997.

The reporting structure for ambulatory care RNs in the outpatient setting may differ from acute care nurses in the inpatient setting. Ambulatory care RNs practice in a variety of health care environments and may report to a non-nurse administrator, in contrast to RNs working in the hospital setting, who usually function as part of an organized nursing department under a nurse executive with voice at the governing body level. However, a change occurring across ambulatory nursing care is the evolution of the Ambulatory Chief Nurse Officer role where RNs report to a nursing executive who has accountability for the nursing clinical care provided in the setting. RNs in ambulatory care settings may work independently or collaboratively within their specialty in partnership with other professional health care providers and paraprofessionals. Nursing Workload: Workload Measurement Nursing workload (numbers of patients seen, assessments completed, and nursing interventions provided) is variable as is the intensity of care delivered, limiting predictability. The appointment system, telephone queues, and patient portal encounters imperfectly predict patient volume. Urgent and emergency patient care needs and walk-in patients create variation in actual workload. Some practices have adopted “overbooking” policies because of high no show rates. These policies further contribute to workload fluctuations. Alternate models of care delivery are being implemented to mediate variability (Haas & Hastings, 2013). Ambulatory workload measurement systems have been developed and 12

are utilized in a growing number of organizations. These tools assist in assessing patient acuity and corresponding patient care needs for nursing care. Delegation. One of the most complex nursing skills for ambulatory care RNs is delegation to ancillary staff. RNs decide what patient care interventions are necessary and how, when, and by whom these interventions need to be provided. These decisions, made in clinical environments with shrinking resources and increased demands for services, heighten the need for nurses to delegate care based on professional guidelines and their state nurse practice acts (Weydt, 2010). Unlicensed staff are abundant throughout ambulatory care; however, when delegating, the RN remains accountable for nursing care. V. The Science and Art of Ambulatory Care Nursing Practice Ambulatory care RN practice is, like nursing practice in general, widely considered art and a science. Nursing is a professional discipline requiring the application of a core body of knowledge from the biological, physical, behavioral, and social sciences. Science of Practice Evidence-based ambulatory care RN practice is grounded in the scientific, investigative, six-step nursing process: nursing assessment, diagnosis, goal/outcome identification, planning, implementation, and evaluation. Nursing care focuses on all phases of health, acute illness, chronic disease, and end of life. RNs assist patients to improve and main-

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tain health and well-being, to prevent or mediate illness, disease, or disability, and experience death with dignity. The nursing needs of patients are assessed holistically using available objective data as well as the subjective data from the patient and caregivers. Nursing diagnoses, plan of care, and interventions are focused on the population and/or individual’s goals and responses to actual or potential health concerns. Evaluation of progress toward outcomes is ongoing. Analytical thinking and critical decision making are essential in all ambulatory care RN roles. Art of Practice The art of ambulatory care nursing considers the patient’s biophysical needs, spiritual needs, cultural preferences, and individual health promotion and disease prevention values. The art of nursing is based on respect for human dignity and compassionate caring, embracing a multitude of dynamic processes that affect human interactions. Listening, assisting, mentoring, coaching, empathizing, teaching, exploring, providing presence and therapeutic touch, cultural competence, accepting, nurturing, and resolving conflicts foster the art of nursing practice (Masters, 2015). Melding the art and science of ambulatory care nursing requires the application of theoretical concepts, scientific research, conscious commitment to caring, and mindful efforts to include caring behaviors during each nurse-patient interaction. By blending the art and science of nursing, nurses can meet their ultimate charge as holistic patient advocates. Professional Responsibilities Professional responsibility as applied to ambulatory care RNs refers to the ethical and moral obligations permeating the nursing profession. These standards relate to patient care, collaboration with other health care professionals, integrity, morals, and the responsibility to effect social change. The best interests of each patient are preeminent above any other concern or bias held by the ambulatory care RN. The RN has a professional obligation to advocate for patients and caregivers. RNs are expected to be moral and express courage and honesty. RNs must accept personal accountability for their own actions and inaction. Further, ambulatory care RNs have an ethical responsibility to be lifelong learners and to spread knowledge and information about health, wellness, and the avoidance of injury and disease. The changing needs of society, the expanding knowledge base of nursing’s theoretical and scientific domains, and evolving health care technology affects the practice of ambulatory care RNs. Responsible ambulatory care RN practice requires multiple and diverse skills: • Visionary leadership in practice settings, community, and profession • Management and organizational • Morally sound personal and professional ethical code

• Continual ambulatory care nursing knowledge development • Review and evaluation of nursing practice • Improvement in the quality of patient and organizational outcomes • Evaluation of safety, effectiveness, and costs when planning and delivering nursing care VI. Ambulatory Care Nursing Roles Ambulatory care nursing is the responsibility of the RN practicing in all the various ambulatory care settings. Working in each of these settings requires a strong clinical background, leadership skills, and autonomous critical thinking. Evidence, science, and art as well as independent expertise is the basis of professional RN practice. This expertise is essential, whether the RN functions on a team of nurses, a team with RNs and other health care colleagues, or is the only RN in the practice. Ambulatory care RNs teach and guide patients in self-efficacy and in making informed decisions about their health. The major professional RN roles in ambulatory care settings include RNs and APRNs. Ambulatory care nursing teams often include licensed practical or vocational nurses (LPNs/LVNs), medical assistants, and technicians. Professional ambulatory care nursing standards address only the minimal expectations of the RN. Professional RNs RNs are those individuals who have successfully completed an educational program in nursing and have passed a national examination for RN licensure. Having passed the national examination, the actual licensure and authorization of RNs to practice nursing is the responsibility of a single state or compact group of states, commonwealths, territories, or provinces. Ambulatory care RNs maintain and extend proficiency through broad and diverse experiences, advanced formal and continuing education, and achieve certification in clinical care, nursing administration, or other specialty roles. AAACN’s position statement emphasizes the importance of RNs in ambulatory care settings: • RNs provide high-quality, evidence-based care across the lifespan to enhance patient safety, reduce adverse events, impact and improve patient satisfaction, support and promote optimal health status, track admissions and readmissions, and manage costs within and among continually expanding, diverse, and complex populations. RNs are essential to the delivery of safe, high-quality care and cannot be replaced by less skilled licensed or unlicensed personnel. • RNs are the team members best prepared to facilitate the functioning of interprofessional teams across the care continuum, coordinate care with patients and their caregivers, and mitigate the growing complexities in care.

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• RNs play a critical role in the delivery of telehealth services and virtual care. The development of the art and science of telehealth practice has improved and expanded coordination of health care services, reduced patient risks, and contributed significantly to care management models (AAACN, 2017a, p. 39). Advanced Practice RNs (APRNs) Ambulatory care advanced practice nurses are RNs who have acquired specialized advanced clinical knowledge and skills to provide health care. Expectations of advanced practitioners include holding a master’s or doctoral degree and an APRN licensure to practice. They have built on the practice of the RN by demonstrating a deeper and broader scope of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and significant role autonomy. APRN is an umbrella term identifying four advanced practice roles in ambulatory care: • Certified RN anesthetist • Certified nurse midwife • Clinical nurse specialist • Nurse practitioner In ambulatory care, APRNs may practice independently or in collaboration with physician staff as providers of health care, directing the patient’s medical diagnosis, treatment, and management. Collegial relations exist between APRNs and the RNs who function in the clinic or in telehealth services. They practice according to standards set by their specialty certification, state law(s), and organizational policies and guidelines. Establishing the professional scope and standards for APRN practice in ambulatory care settings is the responsibility of the appropriate advanced specialty certification organization. However, as the national dialogue regarding expectations of nurse leaders at all levels continues, APRNs prepared at the doctoral level will assume more responsibility for the translation of evidence to practice and population-based outcomes. Clinical Nurse Leader (CNL®) As the complexity of care and systems in the ever-expanding ambulatory care environment continues to grow, it will be increasingly important to develop and define nursing leadership opportunities that focus specifically on nursing practice. The American Association of Colleges of Nursing (AACN) has endorsed the role of the Clinical Nurse Leader as a master’s-prepared nurse leader with advanced accountability for patient care outcomes. Employment of RNs in this role occurs across the continuum of care in any health care setting. These nurse leaders design, implement, and evaluate patient care processes and models of care at the point of care through the application of evidencebased information (AACN, 2013). Further development of this role in ambulatory care settings is critical as nurses assume responsibility for more diverse 14

and complex care delivery, procedural care, and care coordination. Doctorate of Nursing Practice (DNP) The complex and dynamic needs of the health care environment are requiring nurses serving in specialty and leadership positions to have the highest level of scientific knowledge and practice expertise. The DNP-prepared nurse demonstrates a practice that is innovative, evidence-based, and reflects the application of credible research findings. These nurse leaders, often titled Chief Nursing Officer, are educated in systems leadership that provides expertise in evaluating new models of care delivery and the skills needed to create and sustain change at the organizational level. As the number of APRNs increases at the DNP level, the ambulatory care environment will be better equipped to support the adaptation of evidence-based care delivery, the improvement of systems, and the health and wellbeing of populations (AACN, 2015). VII. Professional Trends and Issues Ambulatory care RNs experience similar trends, issues, and concerns as other nurses and organizations face across the health care industry. The field of ambulatory care is growing as the landscape of health care changes from an emphasis on acute care to ambulatory care. There is a shift in focus from illness to health promotion and wellness and fee-for-service to quality performance with both individual patients and populations. General Trends and Issues In the late 20th and early 21st century, the health care industry was facing increasing costs leading to governmental and societal calls for health care reform. Employers paid higher health insurance premiums for their employees, while consumers and beneficiaries experienced increases in deductibles and co-payments. Small businesses were often unable to afford health care insurance for their employees. There were increasing numbers of uninsured patients with limited access and utilization of preventive or health maintenance care. High health care costs and the large number of uninsured patients were causing increased health care encounters in acute, complex, and emergent settings that increased health care expenditures even more. To improve patient safety, a national incentive program to use electronic health records (EHRs) was offered through the American Recovery and Reinvestment Act of 2009 (Singh & Sittig, 2016). Hospitals and health care providers are implementing EHRs, rapidly changing the way ambulatory care RNs function regarding population health, transitions of care, and integrated care plans across the continuum of care. In 2010, the government called for health care reform. With the passing of the PPACA on March 23, 2010, Americans without insurance coverage could choose low-cost insurance coverage in an open

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insurance market. More patients have health care coverage than ever before and the demand for primary care practitioners and ambulatory care RNs surged and continues to rise. Health care is expanding beyond traditional borders. Nurses need to think globally while practicing locally. Ambulatory care RNs, like other colleagues, have concerns with managing patients across state lines and in other countries. Public health concerns have become a part of everyday practice. Varying rules, regulations, and licensing creates potential legal and ethical issues especially with telehealth RN services. Individual state boards of nursing are addressing and supporting this need by participating in nurse licensure compact legislation. Each RN has an obligation to continuously maintain and update knowledge and competency as a lifelong learner. The ambulatory care RN must regularly evaluate the impact of new knowledge, evidence, and change on the scope of ambulatory care RN practice, keeping in mind ethical and legal implications for the patient as well as the nurse. Ambulatory Care Trends and Issues Ambulatory care organizations and RNs face multiple issues and challenging trends. Ambulatory care RNs are on the front line of health care. RNs are pivotal in ensuring individuals have access to care that is appropriate, safe, cost effective, timely, efficient, and equitable, promoting positive patient outcomes. Reimbursement. Opportunities are expanding for reimbursement of ambulatory care nursing services that offer transitional care coordination, health promotion, and illness prevention as an outcome of the PPACA. Patient-Centered Medical Home (PCMH). As the health care industry works to establish the PCMH, ambulatory care RNs have new challenges. The PCMH, is a team-based health care delivery model led by a health care provider that is intended to deliver comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. RNs role in nurse triage and assessment, care coordination, and care management is an essential component of the PCMH. The nurse views care as a continuum and not episodic (Krau, 2015). RNs are required to be flexible, creative, and to think critically to deliver safe and effective patient-centered care 24/7 (Govranos & Newton, 2014). The goal of team-based care is to support the achievement of the quadruple aim of health care reform (Bodenheimer, & Sinsky, 2014): • Improved quality of care • Improved patient experience • Improved health care worker experience • Decreased overall costs of health care Health information technology. Health care and ambulatory care nursing are in continual change due to national quality improvement initiatives and health care reform. There is a national initiative to leverage electronic technology to manage informa-

tion about people’s health and health care, for both individual patients and groups of patients, to enable high-quality and cost-effective care (Agency for Healthcare Research and Quality [AHRQ], 2015). The integration of health information technology (IT) into primary care includes a variety of electronic methods (AHRQ, 2015): • Clinical decision support • Computerized disease registries • Computerized provider order entry • Consumer health IT applications • Electronic medical/health record systems • Electronic prescribing • Telehealth • Interfaced home monitoring Expansion of telehealth. Telehealth RN services increase access to care and facilitate treatment through triage, education, disease or condition management, coordination of appointments, specialist referrals, communication of diagnostic results, and portal messaging. With the explosion of IT, ambulatory care nurses are securely transmitting information to colleagues and patients using multiple platforms of devices and mobile computing devices. Nursing informatics (NI). With the integration of technology into the workplace, a new field of nursing emerged, nursing informatics. The International Medical Informatics Association (IMIA) NI Special Interest Group defined NI as the “science and practice (that) integrates nursing, its information and knowledge, with management of information and communication technologies to promote the health of people, families, and communities worldwide” (Bartz, 2014, p. 229). Nurse informaticists work as developers of communication and information technologies, educators, researchers, chief nursing officers, chief information officers, software engineers, implementation consultants, policy developers, and business owners to advance health care. Core areas of work include: • Concept representation and standards to support evidence-based practice, research, and education. • Data and communication standards to build an interoperable national data infrastructure. • Research methodologies to disseminate new knowledge into practice. • Information presentation and retrieval approaches to support safe patient-centered care. • Information and communication technologies to address interprofessional workflow needs across all care venues (American Medical Informatics Association, 2015). Quality of care and outcomes. The issue of quality of care and performance improvement has increased in visibility and intensity across the health industry, including ambulatory care settings. Ambulatory care organizations and RNs need to partner with the diverse accrediting agencies that affect ambulatory care RN practice and agencies setting the measurement standards for ambulatory

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care. Ambulatory care RNs and organizations need to learn to go beyond structure and process issues. Outcome measures are critical to the future of healthier patients and high-performing organizations. Accountable Care Organizations (ACOs) and value-based purchasing (VBP) are new initiatives by the CMS to improve quality of care and cost effectiveness of care. ACOs are groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high-quality care to their Medicare patients (CMS, 2016). The goal of coordinated care is to ensure patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services, ensuring appropriate preventive services, and promoting a culture of safety. VBP initiatives in hospitals have an impact on ambulatory care nursing (CMS, 2016). VBP has created pressure on acute care areas to discharge patients earlier without complications and outpatient areas to decrease hospital admissions and readmissions. Ambulatory care RNs are managing more medical conditions and diseases telephonically and with clinic visits. Nurse-sensitive indicators. Professional nursing is a critical component of America’s health care. In ambulatory care systems, initially the role of the RN was limited to telephone triage, patient education, and technical procedures (e.g., infusions and medication administration) (Laughlin & Beisel, 2010). More recent studies demonstrate RNs also deliver specific interventions (e.g., screening for depression; monitoring the status of chronic care populations including patients with hypertension, heart disease, diabetes, and allergies; and collaborating with the interprofessional team to improve outcomes) (Morgan et al., 2013; Tomcavage, Littlewood, Salek, & Sciandra, 2012). This growing literature lends support for RN roles to deliver interventions such as evidencebased guidelines, self-care/management, medication teaching, and treatment to target goals to improve clinical outcomes (Trehearne, Fishman, & Lin, 2014). It became that clear ambulatory care RNs needed to identify, define, and report on measurement items that reflect the work, outcomes, and value of ambulatory care nursing practice. In 2014, AAACN established a task force to determine appropriate measures of nursing quality in the ambulatory care setting. The task force spent 2 years investigating the definition of nurse-sensitive indicators in the ambulatory care setting as well as metrics that would reflect the value of the RN to patients and organizations. Significantly, the task force produced an Industry Report that addressed measures of nursing quality (Mastal et al., 2016). In 2016, AAACN partnered with The Collaborative Alliance for Nursing Outcomes (CALNOC) to identify and pilot relevant ambulatory care nursing measures of quality. “CALNOC is the nation’s first registry dedicated to nursing sensitive measures at the unit level. It is a self-sustaining non-profit 16

public benefit corporation with over 15 years’ experience in advancing the safety and quality of patient care.” (CALNOC, 2017, para. 1). Through this partnership AAACN continues the work of identifying, defining, and measuring indicators sensitive to ambulatory care RN practice. These types of endeavors will continue indefinitely. Nurse Residency Programs Over the last 15 years, nurse residency programs have progressively set a new standard for orienting staff to the practice environment. Nurse residencies transcend standard orientation programs in duration, focus, and complexity. They enable the nursing profession to move from a task-focused approach that emphasized doing the job to a multifaceted approach that requires critical thinking, diverse learning experiences, and nursing leadership. Residencies provide a formalized structure that emphasizes the knowledge and skills needed to practice safely and competently (AAACN, 2014). Ambulatory care RNs have historically been experienced nurses. Ambulatory care settings are creating strategies that will provide a healthy pipeline for new graduate RNs to choose and stay in ambulatory care (Haas, 2009). It is critical these strategies include a mentoring environment that introduces and supports the new nurse’s growth of professional knowledge and skills while maintaining a safe patient environment. AAACN developed an ambulatory care residency program that offers new graduates and experienced RNs new to ambulatory care practice an opportunity to participate in a learning environment based on evidence-based practice and a comprehensive, structured approach (AAACN, 2017b). The knowledge and skills needed to practice safely and competently in ambulatory care environments are not identical to those needed to practice in the acute care environment. Residencies have become an effective strategy to meet workforce demands and facilitate the transition of RNs to competent practice. Residency programs have a strong potential to transform the contributions of ambulatory care RNs. Leadership Ambulatory care RNs identify potential nurse leaders and develop leadership competencies for novice and experienced RNs. Analyzing leadership potential in the context of the organization enables RNs to develop leadership skills in the clinical setting, as organizational managers, administrators, or executives in professional nursing organizations or in community agencies (Swan & Moye, 2009). The Future Ambulatory care RNs, regardless of organizational practice settings, will need to continue to partner with other RNs, health care professionals, and community agencies to lead interprofessional teams addressing population health goals and the transition from pay for volume to pay for value.

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Standards of Practice for Professional Ambulatory Care Nursing AAACN, as the specialty nursing organization for RNs practicing in ambulatory care, is responsible for establishing and publishing the standards for ambulatory care RN practice. These standards are authoritative statements that describe the responsibilities for which ambulatory care RNs are accountable. In this edition, the standards occur in two domains: Clinical Practice and Professional Performance. Standards of Professional Clinical Practice The six Clinical Practice Standards address the science and art of RN clinical practice in ambulatory care – the nursing process. The nursing process is a rational, systematic method of planning and providing nursing care. Ida J. Orlando developed the process in the late 1950s, as she observed RNs as they practiced. The profession has refined the process over the intervening decades and now has six steps, applicable to both individuals and populations that are the basis of the standards of clinical practice in nursing (ANA, 2010, 2015): • Assessment: Professional RN’s systematic, dynamic collection and analysis of the patient and/or the population with the presenting concern, using physiological, psycho-socio-cultural, spiritual, economic, and lifestyle data as well as the patient’s response to the problem. • Nursing Diagnosis: Professional RN statement that represents the RN’s clinical judgment about the patient’s response to actual or potential health conditions or needs. • Identification of Expected Outcomes/Goals: Professional RN identifies and specifies the expected outcomes of an individualized plan of therapies and/or treatment(s) using input from the patient/family, other health professionals, and current scientific evidence.

• Planning: Professional RN outlines a set of written statements that identify specific needed services and interventions with measurable and achievable short and long-term goals that meet expected outcomes. • Implementation: Professional RN provides nursing care services to meet the patient’s needs and goals and documents all activities. Implementation involves a variety of roles: • Coordination of Care • Health Teaching and Health Promotion • Telehealth Services • Consultation • Evaluation: Professional RN’s continual appraisal of the patient’s status and the effectiveness of the care received, revising the care plan and interventions as appropriate. Standards of Nursing Organizational and Professional Performance The ten Professional Performance Standards for ambulatory care RNs identify a competent level of behavior in the organizational and professional dimensions of each ambulatory care RN’s specific role. These behaviors include activities related to: · · · · · · · · · ·

Ethics Education Research and Evidence-Based Practice Performance Improvement Communication Leadership Collaboration Professional Practice Evaluation Resource Utilization Environment

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e Standards of Professional Clinical Practic STANDARD 1: Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 STANDARD 2: Diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 STANDARD 3: Outcomes Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 STANDARD 4: Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 STANDARD 5: Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 5a: Coordination of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 5b: Health Teaching and Health Promotion . . . . . . . . . . . . . . . . . 27 5c: Telehealth Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 5d: Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 STANDARD 6: Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

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e Standards of Professional Clinical Practic STANDARD 1 Assessment Standard The RN practicing in the ambulatory care setting systematically collects or supervises the collection of focused data relating to health needs and concerns of a patient, group, or population.

Competencies Ambulatory care RNs: 1. Establish a therapeutic rapport with patient and caregivers as well as determine the patient’s perception of his or her immediate needs and concerns. 2. Identify barriers to providing optimal care (e.g., language, culture, and behavioral health issues). 3. Collect or validate the collection of subjective and objective health data from multiple primary and secondary sources. 4. Use applicable evidence-based assessment techniques and instruments related to ambulatory care nursing in collecting pertinent patient or population data. 5. Prioritize data collection activities based on the patient’s, group’s, or population’s immediate health need or the nurse’s clinical expertise of anticipated patient needs. 6. Synthesize available data, information, and nursing knowledge relevant to the presenting health situation to identify patterns and variances as well as gaps in care. 7. Prioritize the data and information collected based on the patient’s or population’s condition and preferences, situation, and/or anticipated needs. 8. Document the information and data collected in a retrievable, understandable, and readable format. 9. Reassess the patient and situation as needed to address alterations in health status.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Use evidence-based practice guidelines to determine and/or refine data collection and analysis processes. 2. Identify the essential elements of assessment and documentation for a given practice setting. 3. Establish training, education, and resources on evidence-based assessment techniques for all nursing staff. 4. Ensure information systems are in place that support the input and retrieval of reliable patient data. 5. Establish assessment expectations and monitor individual nursing staff performance.

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e Standards of Professional Clinical Practic STANDARD 2 Diagnoses Standard The RN practicing in the ambulatory care setting analyzes the assessment data to determine the diagnostic statements for health promotion, health maintenance, or health-related problems or issues. .

Competencies Ambulatory care RNs: 1. Identify the diagnoses, actual or potential, based on the analysis of assessment data and information, current ambulatory care RN knowledge, and evidence based practice(s). 2. State the diagnoses using standardized language, and understandable and recognized terminology utilizing clinical decision-support tools. 3. Validate the diagnoses and/or issues with the patient, caregivers, and other members of the interprofessional health care team when appropriate. 4. Prioritize the diagnoses based on the patient’s condition, expectations and preferences, situation, cultural and age-specific considerations, and/or anticipated needs. 5. Document clearly the diagnoses to facilitate the determination of expected outcomes and plans.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Support and evaluate staff competency in the development of nursing diagnoses. 2. Provide educational opportunities and resources for professional nurses to develop and utilize nursing diagnostic statements related to ambulatory care. 3. Facilitate data analysis and decision-making processes to define practice patterns. 4. Promote an organizational climate that supports the validation of nursing diagnostic statements relevant to ambulatory care.

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e Standards of Professional Clinical Practic STANDARD 3 Outcomes Identification Standard The RN practicing in the ambulatory care setting identifies expected and/or desired outcomes in a plan of care individualized for a specific patient, group, or population.

Competencies Ambulatory care RNs: 1. Derive expected outcomes from the diagnosis(es). 2. Involve the patient, family, and health care team in formulating measurable expected outcomes. 3. Consider associated risks, benefits, costs, current scientific evidence, and clinical expertise when formulating measureable expected outcomes. 4. Define expected outcomes in terms of the patient values, preferences, spiritual, emotional, cultural and ethical considerations, age-related issues, and situational environment. 5. Specify a time estimate for attainment of measurable expected outcomes. 6. Develop measureable expected outcomes that provide direction(s) for continuity of care. 7. Modify measurable expected outcomes based on changes in the status of the patient or reevaluation of the plan of care. 8. Document expected outcomes as realistic, attainable, and measurable goals.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Participate in the design, development, and maintenance of the interprofessional processes that establish and sustain standards consistent with quality outcomes. 2. Support the identification, development, and utilization of databases that include nurse-sensitive indicators, metrics, and quality outcomes. 3. Engage professional nurses in monitoring and evaluating nursing care in accordance with established professional, regulatory, and organizational standards of practice. 4. Advocate for and allocate the resources to establish and continuously improve clinical guidelines that ensure continuity of care. 5. Collaborate with appropriate departments and other professionals in developing integrated systems that support ambulatory care nursing. 6. Initiate activities that improve nursing practice, organizational performance, and optimal patient and population outcomes.

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e Standards of Professional Clinical Practic STANDARD 4 Planning Standard The RN practicing in the ambulatory care setting develops a plan that identifies strategies and alternatives to attain expected outcomes in individuals and/or populations.

Competencies Ambulatory care RNs: 1. Develop an individualized ambulatory care nursing plan for patients seeking care for health promotion, health maintenance, or health-related situational problems. 2. Apply current ambulatory care nursing knowledge and evidence-based nursing practices in the plan of care. 3. Include the patient, family, or caregivers as appropriate and the health care team in making shared decisions about prioritizing plans and strategies. 4. Consider patient or population needs in terms of age, gender, race, cultural values and practices, ethical and legal considerations, environmental factors, and the anticipated risks and benefits of interventions for individualized plan development. 5. Incorporate a timeline for ambulatory care nursing plan implementation and goal achievement, reevaluation or reassessment, follow-up care, and care coordination as appropriate. 6. Ensure plan activities reflect current rules, regulations, and statutes. 7. Develop a plan with consideration of the most valid, cost-effective, evidence-based care and integrate current trends and available research. 8. Consider the economic impact of the plan on patient and family resources. 9. Document the plan and the patient’s progress to ensure continuity of care using recognized terminology. 10. Provide a plan of care that is clear and understandable to patient, family, and/or caregivers.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Facilitate the development and improvement of organizational systems in which plans related to ambulatory care nursing services can be developed, documented, and evaluated. 2. Facilitate the development and continuous improvement of mechanisms for plans to be recorded, reviewed, evaluated, and updated. 3. Promote the integration of ambulatory care organizational and management theories, nursing and related research findings, practice standards, and guidelines into the planning process. 4. Support staff in developing and maintaining competency in the planning process. 5. Collaborate with appropriate departments and/or disciplines so the organizational system operates effectively and efficiently to achieve improved outcomes.

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e Standards of Professional Clinical Practic STANDARD 5 Implementation Standard The RN practicing in the ambulatory care setting enacts the identified plan of care.

Competencies Ambulatory care RNs: 1. Prioritize interventions based on the patient’s health status, preferences, resources, motivation, and anticipated needs. 2. Facilitate the implementation of the interprofessional plan of care in partnership with the patient and caregivers, in a safe, efficient, and timely manner. 3. Utilize the unique knowledge, skills, and competencies required in ambulatory care nursing practice to promote wellness, restore health, and support end-of-life care. 4. Utilize evidence-based, ambulatory care-specific interventions to achieve agreed upon outcomes during clinical visits, telephone encounters, and electronic communications according to state regulations, regulatory agency standards, and appropriate organizational policies and procedures. 5. Provide age-appropriate, population-specific care in a compassionate, holistic, culturally and ethnically sensitive manner, with a focus on the patient’s communication preferences. 6. Utilize available organizational technology to implement plan of care. 7. Document nursing interventions and services provided in the patient record, including modifications, changes, or omissions of the identified plan (ANA, 2015). 8. Advocate for the health needs of individuals and diverse populations across the lifespan and the continuum of care.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Establish and promote organizational processes, systems, and resources to effectively implement plans of care. 2. Lead and facilitate change in organizations to improve implementation of evidence-based ambulatory care nursing interventions and strategies. 3. Lead and collaborate in improvement of information systems that facilitate accurate and complete documentation of nursing care. 4. Assure principles of quality are integrated in organizational standards and policies that affect implementation of nursing plans of care. 5. Serve as an expert resource and consultant in assuring standards of ambulatory care nursing practice are integrated into organizations and health systems.

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e Standards of Professional Clinical Practic STANDARD 5a Coordination Of Care Standard The RN practicing care coordination and transition management (CCTM®) coordinates the delivery of care within the practice setting and across health care settings.

Competencies Ambulatory care RNs: 1. Demonstrate accountability across the care settings in maintaining continuity of care. 2. Facilitate patients’ and/or populations’ progress toward positive person-centered clinical outcomes. 3. Utilize an interprofessional approach to engage patient, caregivers, and providers in implementing the plan of care across care settings. 4. Facilitate the transition of patient/populations to the appropriate level of care. 5. Educate and activate patient and caregivers for optimal disease management by promoting healthy lifestyle changes in the prevention of illness across population(s). 6. Prevent disease progression by reducing risk factors. 7. Recognize and maximize opportunities to increase the quality of care. 8. Manage high-risk individuals and/or population(s) with the aim of preventing or delaying adverse outcomes. 9. Communicate the relevant information to patient, caregivers, and interprofessional health care team across the care continuum. 10. Apply effective teamwork and collaboration skills to overcome identified barriers to produce quality and effective patient outcomes.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Plan the global CCTM functions that meet the population’s needs and are sustainable for the health care system. 2. Establish practice standards for evidence-based care delivery. 3. Communicate and build relationships with applicable stakeholders across the care continuum. 4. Develop and validate staff competencies consistent with standards of nursing practice and organizational policies for CCTM. 5. Ensure regulatory compliance with external accrediting organization(s).

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e Standards of Professional Clinical Practic STANDARD 5b Health Teaching and Health Promotion Standard The RN practicing in the ambulatory care setting employs educational strategies that promote individual, community, and population health and safety.

Competencies Ambulatory care RNs: 1. Assess a group or patient’s learning needs, abilities, readiness, preferences, and barriers to learning. 2. Utilize health teaching and health-promotion strategies which support the patient’s learning needs, values, preferred language, socioeconomic status, cultural, and spiritual preferences. 3. Provide accurate and timely information to support patient and caregivers in navigating the health care delivery system, including services, access to care, and available resources. 4. Assure patient and caregivers understand intended outcomes and potential risks related to the plan of care. 5. Address and reinforce the patient’s age-specific and developmental needs related to plan of care. 6. Support patient and caregivers in developing skills for self-efficacy to promote, maintain, or restore health, such as healthy lifestyles and risk-reducing behaviors. 7. Continuously evaluate learner comprehension and effectiveness of teaching strategies and nursing interventions based on feedback from patient, caregivers, and health care team. 8. Document learner assessment, comprehension, and effectiveness of educational strategies, as well as modifications to plan of care, based on patient feedback and progress toward identified outcomes. 9. Utilize current technology in providing health-promotion and disease-prevention strategies for optimal patient outcomes. 10. Remain knowledgeable regarding current population health recommendations to provide accurate, evidence-based anticipatory guidance to patients. 11. Promote and practice healthy self-care activities and stress management strategies and advocate for organizational policies and programs that promote a healthy workplace environment.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Engage in a systematic evaluation of nursing educational processes and practices. 2. Design, implement, and sustain workplace environments that promote positive, collegial staff interactions. 3. Utilize current evidence-based frameworks to design and implement health education information and programs. 4. Engage leaders and consumer alliances in integrating health-promotion activities at the organizational and community levels. 5. Serve as role models for healthy self-care activities and stress management.

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e Standards of Professional Clinical Practic STANDARD 5c Telehealth Services Standard The RN practicing in the ambulatory care setting providing telehealth services adheres to the current AAACN Scope and Standards of Practice for Professional Telehealth Nursing in all practice environments.

Competencies Ambulatory care RNs: 1. Utilize current and evolving electronic information and telecommunication technologies to minimize time and distance barriers for the delivery of nursing care. 2. Coordinate interprofessional services across the care continuum. 3. Provide efficient, effective, and evidence-based care within the telehealth services framework. 4. Complete timely and accurate documentation of patient information and care interactions. 5. Utilize the nursing process in managing patient telecommunication encounters. 6. Apply principles of ergonomics and safe work settings.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Ensure the quality of telehealth nursing services through effective orientation and continuing education of nurses. 2. Evaluate and incorporate current and evolving telecommunications technologies. 3. Ensure competency, quality, and consistency of telehealth nursing performance. 4. Ensure compliance with organizational, professional, and regulatory standards. 5. Ensure a safe work environment and applicable resources.

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e Standards of Professional Clinical Practic STANDARD 5d Consultation Standard The RN practicing in the ambulatory care setting provides consultation in developing interprofessional plans of care, enhancing the ability of other professionals and effecting change.

Competencies Ambulatory care RNs: 1. Synthesize clinical data and best practices when providing consultation across the care continuum. 2. Consult with appropriate stakeholders.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Facilitate the collaboration among the interprofessional team to enhance the decision-making process and assignment of role responsibilities.

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e Standards of Professional Clinical Practic STANDARD 6 Evaluation Standard The RN practicing in the ambulatory care setting evaluates progress toward attainment of stated outcomes.

Competencies Ambulatory care RNs: 1. Conduct systematic, ongoing, and criteria-based evaluation of patient and/or population outcomes prescribed by the plan of care and the indicated timeline. 2. Integrate current evidence-based care into the evaluation process. 3. Include patient, caregivers, and all others involved in the care of the patient in the evaluation process. 4. Consider patient and family values, preferences, socio-economic, political, religious, cultural, and environmental factors in evaluating the expected outcomes of the plan of care. 5. Reevaluate expected outcomes and the plan of care as indicated. 6. Document patient status, evidence of patient and family participation and responses, including the rationale for revisions in plan of care. 7. Communicate evaluation outcomes to patient, caregivers, and all other stakeholders as appropriate.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Facilitate the formation of groups of ambulatory care nurses and other health care professionals to develop analytical tools to enhance the evaluation process. 2. Synthesize the evaluation results and their effect on ambulatory care nursing practice and patient and/or population outcomes. 3. Use research findings, clinical guidelines, and evaluation results to improve care, services, and outcomes. 4. Advocate and encourage nursing staff to participate in decision making related to evaluation processes.

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d Standards of Nursing Organizational an Professional Performance STANDARD 7: Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 STANDARD 8: Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 STANDARD 9: Research and Evidence-Based Practice . . . . . . . . . . . . . . . . . .35 STANDARD 10: Performance Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . .36 STANDARD 11: Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 STANDARD 12: Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 STANDARD 13: Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 STANDARD 14: Professional Practice Evaluation . . . . . . . . . . . . . . . . . . . . . . .41 STANDARD 15: Resource Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42 STANDARD 16: Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

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d Standards of Nursing Organizational an Professional Performance STANDARD 7 Ethics Standard The RN practicing in the ambulatory care setting incorporates professional codes of ethics with compassion and respect for the inherent dignity, worth, and unique attributes of every person.

Competencies Ambulatory care RNs: 1. Participate in the identification and resolution of ethical concerns using the nursing process incorporating nursing’s professional code of ethics and organizational policies. 2. Actively engage in addressing the ethical concerns of patients, colleagues, or systems through dialogue with nursing colleagues, nursing managers, and interprofessional communication including members of the organizational ethics committee. 3. Apply knowledge of principles contained in the American Nurses Association Social Policy Statement and Code of Ethics as evidenced by nursing care and professional interactions. 4. Serve as the patient’s advocate in matters of rights to confidentiality, privacy, and self-determination within legal, regulatory, and ethical parameters. 5. Ensure patient care reflects the cultural, spiritual, intellectual, age, educational, and psychosocial differences of individual patients, families, groups, and communities. 6. Disclose any observed illegal or incompetent practices including decisions made by impaired health care (or potentially impaired) personnel to supervisory leadership, appropriate professional bodies, and reporting agencies. 7. Educate and support patients in developing skills for self-efficacy. 8. Ensure informed decision making by the patient or legally designated representative. 9. Ensure patients have opportunities to voice opinions, without fear of recrimination, regarding care and services received, and to have these issues reviewed and resolved per organizational policy and regulatory guidelines. 10. Demonstrate therapeutic interactions with patients and effective interactions with colleagues/staff while maintaining professional boundaries. 11. Demonstrate activities consistent with self-efficacy through personal and professional growth. 12. Engage in activities that promote an ethical environment for the provision of patient care and interactions with co-workers.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Model ethical practices in all business and patient care interactions, including adherence to regulatory and professional ethical and practice standards. 2. Create and maintain a just culture through transparent communication, nondiscriminatory and equitable human resource practices, as well as judicious use of human and material resources. 3. Actively participate in decisions that address ethical risks, benefits, and outcomes for patients and staff.

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d Standards of Nursing Organizational an Professional Performance STANDARD 8 Education Standard The RN practicing in the ambulatory care setting attains knowledge and competency that reflects current ambulatory care nursing practice.

Competency Ambulatory care RNs: 1. Pursue educational and professional experiences that expand their ambulatory care nursing knowledge, skills, and competencies. 2. Participate in ongoing, diverse educational activities related to appropriate ambulatory care nursing and health care knowledge, health system effectiveness, and informatics and professional issues. 3. Use current research findings and other evidence to expand professional knowledge, enhance role performance, and increase knowledge of ambulatory care nursing professional issues. 4. Demonstrate a commitment to lifelong learning through self-reflection and inquiry to identify learning needs. 5. Seek experiences that reflect current practice to maintain skills and competence in ambulatory care nursing clinical and professional practice or role performance. 6. Acquire knowledge and skills appropriate to the ambulatory care nursing specialty area, practice setting, role, or situation. 7. Actively seek, encourage, and support certification in a clinical specialty. 8. Maintain personal professional records that include evidence of current licensure, evaluation, and validation of clinical competence, continuing education, and certification in a health care specialty or verification of special skill sets. 9. Promote the strength and effectiveness of the ambulatory care nursing profession through membership and active participation in professional and community organizations. 10. Mentor and support new nurses to the ambulatory care nursing setting, incorporating them into interprofessional activities and ongoing continuing education.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Ensure education and training opportunities are available for continued nursing knowledge development, competency validation, and evidence-based nursing practice. 2. Maintain employee records that provide evidence of competency and lifelong learning. 3. Reward and recognize nurses’ certification in a specialty area. 4. Advocate for and support the attainment of advanced degrees in nursing. 5. Advocate for organizational policies that support nursing educational opportunities and ongoing nursing education. 6. Encourage attendance and participation in educational conferences and active membership within professional organizations. 7. Partner with schools of nursing to provide an environment for students that is conducive to actively learning principles and practices of ambulatory care nursing. 8. Ensure access to evidence-based journals and other clinical resources. 9. Ensure all RNs new to ambulatory care practice receive a comprehensive evidence-based ambulatory care nurse orientation or residency program.

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d Standards of Nursing Organizational an Professional Performance STANDARD 9 Research and Evidence-Based Practice Standard The RN practicing in the ambulatory care setting actively participates in evidence-based practice initiatives and research activities to advance ambulatory care nursing and improve patient outcomes.

Competency Ambulatory care RNs: 1. Review and evaluate current literature for research and evidence relevant to ambulatory care nursing practice. 2. Utilize current research findings and other evidence to expand professional knowledge, enhance role performance, and increase knowledge of ambulatory care nursing professional issues. 3. Identify clinical problems related to patient care delivery and/or ambulatory care nursing practice. 4. Evaluate the research evidence using criteria for scientific merit and optimal application in clinical practice settings. 5. Disseminate relevant evidence and research findings across organizational, community, and professional forums. 6. Integrate evidence and research findings into clinical practice. 7. Evaluate and reevaluate the outcomes of evidence-based interventions. 8. Initiate, support, and/or participate in clinical nursing, health care, and health system research studies conducted by professional, credentialed researchers.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Institute strategies that facilitate the utilization of research as an evidence base for professional ambulatory care nursing practice. 2. Use research findings and/or evidence-based practices in the development of all applicable policies, procedures, and guidelines for patient care. 3. Ensure research conducted in the clinical and/or organizational environment undergoes review and approval by an Institutional Review Board and adheres to ethical principles. 4. Validate research studies are congruent with organizational and national goals and priorities for applicability to ambulatory care nursing practice. 5. Serve as a champion for nursing staff to participate in learning opportunities, organizational quality and performance improvement activities, and relevant research initiatives that advance the delivery of ambulatory care nursing and health care services in the outpatient setting. 6. Promote the integration of nursing research into clinical practice to improve quality. 7. Balance the costs and benefits to patients, staff, and the organization of participating in research studies. 8. Advocate for adequate organizational resources to enable nurses to learn and participate in evidencebased nursing practice, nursing research, and scholarly inquiry. 9. Evaluate the demands on staff and organizational resources prior to participating in research studies. 10. Collaborate with organizational and nursing colleagues to establish opportunities for nursing staff to participate in research/research findings implementation. 11. Actively participate in studies that offer potential for enhancing patient care delivery and care outcomes, nursing practice, and organizational/system effectiveness. 12. Support and encourage nurse researchers to disseminate findings through activities such as presentations, publications, consultations, professional nursing organizations, journals, and clubs. 13. Reward and recognize staff for participation in evidence-based practice and research activities. Scope and Standards of Practice for Professional Ambulatory Care Nursing – 9th Edition – 2017

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d Standards of Nursing Organizational an Professional Performance STANDARD 10 Performance Improvement Standard The RN practicing in the ambulatory care setting enhances the quality, efficiency, and effectiveness of clinical and professional nursing practice and organizational system.

Competencies Ambulatory care RNs: 1. Continuously evaluate ambulatory care clinical nursing practice to identify opportunities for improving clinical outcomes, safety, and patient experience. 2. Participate in the identification and definition of nurse-sensitive indicators. 3. Lead and/or participate in quality and performance improvement initiatives within the organization and across the care continuum. 4. Evaluate and disseminate the findings of quality and performance improvement initiatives. 5. Implement evidence-based improvements into ambulatory care clinical, organizational, and professional practice. 6. Foster an environment which encourages patients, families, caregivers, visitors, and staff to provide input for patient care improvement activities. 7. Mitigate actual or potential risks to patient and staff safety.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Solicit input from staff, patients, and families to identify strategies that improve patient care and organizational services. 2. Lead the development, implementation, and evaluation of current and innovative care delivery models. 3. Identify opportunities and establish priorities to continuously improve nursing quality of care and organizational performance. 4. Establish and communicate expectations for staff to participate in performance improvement initiatives. 5. Provide resources and opportunities to implement quality of care and performance improvement activities. 6. Foster interprofessional communication, collaboration, and coordination of improvement efforts. 7. Mentor, recognize, and reward nurses who participate in quality improvement activities. 8. Ensure the systematic aggregation and analysis of quality data, and the use of appropriate statistical tools and techniques. 9. Trend and benchmark data to identify variances and improve the quality, efficiency, and effectiveness of care, and patient safety and satisfaction. 10. Mitigate actual and potential risks to patients and staff safety at the leadership level. 11. Advocate for integration of quality improvement activities that foster excellence in nursing care into the organizational strategic plan. 12. Evaluate the efficiency and effectiveness of quality nursing care across the care continuum. 13. Partner with colleagues to conduct joint quality improvement initiatives. 14. Advocate for the identification and adoption of nurse-sensitive indicators and metrics that identify the value of nursing in improved patient/population care and outcomes. 15. Create an environment that recognizes and rewards nursing excellence.

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d Standards of Nursing Organizational an Professional Performance STANDARD 11 Communication Standard The RN practicing in the ambulatory care setting communicates effectively using a variety of formats, tools, and technologies to build professional relationships and deliver care across the continuum.

Competencies Ambulatory care RNs: 1. Promote active communication using techniques that enhance learning and sharing of information. 2. Identify and evaluate personal skills and styles of communication to enhance effectiveness. 3. Share ambulatory care nursing best practices with peers, requesting feedback and evaluation. 4. Maintain professional communications with all members of the interprofessional health care team and other stakeholders. 5. Contribute to a positive environment that fosters information sharing and learning. 6. Seek opportunities to create mentoring relationships among ambulatory care nurses. 7. Communicate knowledge and skills acquired through formal and informal professional development activities. 8. Exemplify a positive attitude and professional nursing practice that fosters a sense of excellence and enthusiasm among peers and colleagues.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Foster a positive environment of collegiality and trust through shared interprofessional communication, experience, and decision making. 2. Seek, evaluate, and implement modern communication tools and technologies that improve ambulatory care nursing interactions and promote positive outcomes. 3. Act as a resource and role model for positive, professional communication with all members of the interprofessional care team across the health care continuum. 4. Recognize individual accomplishments and skills of staff members to foster a sense of professional pride, departmental expertise, and information sharing. 5. Engage with professionals and organizational decision-making bodies to improve professional practices, environment, and outcomes.

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d Standards of Nursing Organizational an Professional Performance STANDARD 12 Leadership Standard The RN practicing in the ambulatory care setting demonstrates leadership behaviors in practice settings, across the profession, and in the community.

Competencies Ambulatory care RNs: 1. Demonstrate respect for the dignity, worth, and contributions of others. 2. Acknowledge and learn from mistakes, taking remedial action as needed. 3. Recognize, address, and mitigate workflow inefficiencies. 4. Proactively anticipate and recognize the needs of others, using positive interactions and creative solutions to achieve effective outcomes. 5. Actively advocate for collegial, safe environments in ambulatory care clinical practice, organizational environments, and community settings. 6. Train and mentor newly assigned personnel and students. 7. Assume responsibility and accountability for coordinating all aspects of the nursing process including delegated care. 8. Lead and participate in process improvement teams, committees, and activities related to nursing and health care practice in clinical, organizational, and community settings. 9. Collaborate with the interprofessional health care team to build and maintain an effective and dynamic professional relationship. 10. Participate actively in organizational shared decision-making situations that improve ambulatory care nursing practice, organizational performance, and outcomes. 11. Promote the continued growth, strength, and effectiveness of professional ambulatory care nursing through membership and active participation in professional and community organizations. 12. Cultivate and sustain a culture of safety. 13. Collaborate with colleagues through membership in professional ambulatory care nursing organizations.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Inspire nursing staff with a shared vision and direction for continuous quality improvement. 2. Lead and support activities that improve nursing practice, organizational performance, and healthy patient outcomes. 3. Build learning environments addressing shared decision making, evidence-based practice, organizational strategic direction, and advances in the health care industry. 4. Lead small and large-scale evidence-based change that is sensitive to organizational culture and the values and perspectives of personnel. 5. Utilize transformational leadership to inspire shared practice and professional accountability. 6. Utilize conflict management skills to mediate professional and workplace issues resulting in mutually acceptable resolutions. 7. Acknowledge and reward contributions of individual personnel and high-performing teams. 8. Influence decision-making bodies to formulate standards that enhance professional nursing and health care practices, expand health system capabilities, and improve the health of individuals and the community.

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d Standards of Nursing Organizational an Professional Performance STANDARD 12 Leadership (continued) 9. Create a culture of safety that fosters the reporting of unsafe conditions without fear of reprisal. 10. Advocate for and promulgate widespread use of quality measures and health information technologies that facilitate nurse efficiency, achievement of quality outcomes, and improved patient and population management. 11. Communicate nursing-sensitive indicators that highlight nursing’s role and value-added contributions within the organization. 12. Lead strategic, operational, and financial plans that impact the delivery of ambulatory care nursing services. 13. Contribute to the expansion of ambulatory care nursing practice through membership and leadership in professional nursing organizations (Chassin & Loeb, 2011).

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d Standards of Nursing Organizational an Professional Performance STANDARD 13 Collaboration Standard The RN practicing in the ambulatory care setting collaborates with patients, family members, caregivers, and other health professionals in the conduct of ambulatory care nursing practice.

Competencies Ambulatory care RNs: 1. Communicate openly with patients, caregivers, and other health care professionals regarding patient care and the ambulatory care nurse’s role in the provision of care. 2. Partner with patients, caregivers, other health care providers, and resource agencies to develop a documented plan of care that promotes positive patient outcomes. 3. Use effective professional communication skills and tools to acquire and disseminate relevant information to patients, caregivers, and health care providers across the care continuum. 4. Collaborate with colleagues to identify and rectify gaps in care and organizational inefficiencies to effect improved outcomes. 5. Share knowledge and skills with peers and colleagues as evidenced by such activities as patient care conferences or presentations at formal or informal meetings. 6. Proactively recognize the needs of others, using positive interactions and creative solutions to achieve effective outcomes.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Collaborate with professional nursing staff, using shared decision making, to implement the scope of ambulatory care nursing practice and standards across the organization for RNs and technical and assistive nursing personnel. 2. Collaborate with organizational colleagues and act within organizational guidelines to formulate strategic, operational, and financial plans that: • Establish the parameters and allocate the resources required to deliver safe, evidence-based, affordable, culturally competent, and age-relevant nursing care and services. • Maintain communication conduits that promote nurses collaborating with other health care team members. 3. Advocate during budgeting cycles for the funding of appropriate staff positions, professional development and training, equipment, and supplies that ensure the delivery of safe, cost-effective, quality ambulatory care nursing services. 4. Cultivate relationships that ensure representation of nursing on organizational decision-making boards and committees. 5. Collaborate at all levels of the organization to create an environment of professional excellence, transparency, and continuous learning. 6. Participate on interprofessional teams that contribute to role development and, directly or indirectly, advance ambulatory care nursing practice and health services. 7. Institute policies and practices that include professional nursing staff in making shared decisions related to ambulatory care nursing practice and nurse-related patient care issues.

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d Standards of Nursing Organizational an Professional Performance STANDARD 14 Professional Practice Evaluation Standard The RN practicing in the ambulatory care setting evaluates his or her own and others nursing practice in relation to professional practice standards and guidelines, patient outcomes, organizational policies and procedures, and relevant governmental regulations and statutes.

Competency Ambulatory care RNs: 1. Utilize ongoing and systematic evaluations of work processes and individual performance standards. 2. Take action to achieve goals identified during the professional practice evaluation process. 3. Use evidence-based rationale for practice decisions and actions as part of informal and formal professional practice evaluation. 4. Engage in evaluation of self and other professional nursing staff to improve ambulatory care nursing practice. 5. Engage in regular organizational performance reviews to identify strengths, opportunities for growth, and set performance goals and objectives. 6. Use available organizational systems and tools to perform reviews and evaluation of ambulatory care nursing practice. 7. Take responsibility for regular review of one’s professional portfolio.  8. Evaluate ambulatory care professional nursing practice based on use of independent nursing judgment, appropriate self-regulation, and accountability. 9. Actively seek feedback regarding one’s own ambulatory care nursing practice from patients, peers, professional colleagues, and others. 10. Participate in department and organizational peer review, mentoring, and coaching regarding professional practice or role performance.

Additional Competency for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Establish a culture of excellence within the organization through thoughtful consistent review and evaluation of evidence-based practices and quality measures within departments, nursing practices, and clinical training.  2. Institute a comprehensive process of employee performance appraisal that may encompass management feedback, peer reviews, patient and/or family comments, and interprofessional responses. 3. Support and facilitate staff involvement in the identification of clinical, ethical, and legal issues through participation in risk management and peer review. 4. Encourage staff involvement in developing systematic approaches for use across the organization to evaluate and improve professional ambulatory care nursing practice.

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d Standards of Nursing Organizational an Professional Performance STANDARD 15 Resource Utilization Standard The RN practicing in the ambulatory care setting utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, and fiscally responsible.

Competencies Ambulatory care RNs: 1. Partner with patients and caregivers to identify patient needs and the resources available to achieve desired outcomes. 2. Implement effective and cost-appropriate ways to maximize wellness, prevent illness, and manage acute and chronic diseases and disabilities to effect the best attainable health status over the patient’s lifespan, up to and including a peaceful death. 3. Delegate to appropriate members of the care team when RN level of care is not required, following applicable laws and regulations. 4. Advocate for the patient and caregiver(s) to access appropriate and available resources to meet their health needs and concerns. 5. Evaluate the impact of resource allocation on the potential for harm, complexity of the task, and desired outcomes. 6. Educate and support the patient and caregiver(s) to become informed consumers about the options, costs, risks, and benefits of health care services.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care executives, administrators, and managers: 1. Assess the needs of the population served and resources available to achieve desired health outcomes. 2. Design innovative solutions to ensure organizational resources, including telehealth services and mobile health technologies, are appropriately allocated and deployed based on evidence of effectiveness, efficiency, and potential for harm. 3. Ensure written organizational charts delineate nursing authority, accountability, chain of command, and lines of communication among nurses and other members of the interprofessional team. 4. Provide clearly defined, written position descriptions and performance standards for each category of nursing and assistive personnel that describes accountability for each employee’s scope of practice and role within the interprofessional team. 5. Implement a staffing plan within organizational guidelines to ensure equitable workloads and that sufficient nurses and assistive personnel are available to deliver safe, quality patient care and improved organizational performance. 6. Create evaluation strategies that address cost effectiveness, cost benefit, and efficiency factors associated with nursing practice.

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d Standards of Nursing Organizational an Professional Performance STANDARD 16 Environment Standard The RN practicing in the ambulatory care setting actively engages in initiatives that create and maintain an environment of care that is safe and hazard free.

Competencies Ambulatory care RNs: 1. Promote a safe and healthy workplace and professional practice environment. 2. Maintain professional practices and boundaries that ensure patients’ privacy, security, and protection of their health information. 3. Integrate into daily practice written policies and procedures that relate to standard precautions, confidentiality, infection control, fire, safety, security, harassment, workplace violence, equipment management, hazardous waste handling, and emergency situations. 4. Utilize screening and preventive programs and appropriate interventions if untoward occupational exposure occurs and/or if risk to occupational exposure is reasonably anticipated, ensuring all actions: · Maintain confidentiality of information related to employee exposure to infectious disease, treatment, and follow-up. · Comply with organizational policies, protocols, and guidelines and evidence-based practices addressing prevention of infection, development of allergic reactions, appropriate disposal of biohazardous and hazardous waste, reporting of malfunctioning equipment, and maintenance of a safe, comfortable environment. 5. Utilize current, available medications, medical equipment, supplies, and technology in the practice environment.

Additional Competencies for Nurse Executives, Administrators, and Managers Ambulatory care nurse executives, administrators, and managers: 1. Understand and implement applicable federal and state rules and regulations, organizational policies, and evidence-based practice to determine resources needed for delivery of safe, quality patient care. 2. Ensure there are programs for all staff that address mitigating real or potential occurrences of workplace violence. 3. Ensure there are written and widely communicated standards for the identification, prevention, and management of infections and communicable diseases. 4. Make recommendations and advocate for the deployment of appropriate staff based on the volume and complexity of care in accord with the state’s nurse practice act, professional standards of safe practice, and organizational policy. 5. Maintain current standards of practice and clinical guidelines for the provision of culturally aligned and relevant ambulatory care nursing in diverse outpatient practice settings. 6. Ensure physical space accommodates the delivery of nursing care and administrative activities associated with the patient encounter including age-specific, disability-specific, and diverse population needs. 7. Partner with other health care organizations and agencies to promote healthy communities.

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GLOSSARY Many terms in nursing and health care have multiple meanings and can be used in multiple contexts. Certain terms are defined to clarify the intent and application of these standards. Terms not defined are assumed either to have a generally acceptable meaning and interpretation, or to require contextual interpretation depending on the setting and application. Adverse Event – Unnecessary patient injury, harm, pain, suffering, or death resulting from either medical management or health system process rather than from illness or disease. Advocacy – The act or process of advancing or supporting (a cause or proposal) on behalf of another. Care Continuum (Continuum of Care) – Over the course of the patient’s life, he or she will receive health-related care from a variety of health care and service professionals in a variety of health care settings. Care Coordination – The deliberate organization of patient care activities between two or more participants (including the patient) involved in the patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities and often it is managed by the exchange of information among participants responsible for different aspects of care. Caregiver – Individual (e.g., a family member, friend, or companion) over the age of 18 years who provides care and/or support. Care Transitions – A change in the level of service or location of providers of care as patients move within and across the health care system. Collaboration – Working together toward a common goal; to pursue a common purpose and a sharing of knowledge and information to decide issues, resolve problems, and set goals within a structure and relationship of collegiality. Competence – Having the ability to demonstrate knowledge, technical, critical-thinking, and interpersonal skills necessary to perform one’s role and job responsibilities. Competency – An expected level of performance that integrates knowledge, skills, abilities, and judgment. Continuity of Care – Health care that remains consistent or uninterrupted throughout the care process. Continuum of Care – Over the course of a lifetime, a person receives health-related care from a variety of health care and service providers in a variety of health care settings. Critical Thinking – Intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action. This skill is demonstrated in nursing by exercising clinical judgment that also encompasses ethical, diagnostic, and therapeutic research dimensions (The Critical Thinking Community, 2016).

Cultural Competence – Requires developing cultural awareness (conscious learning process through which one becomes appreciative and sensitive to the cultures of other people), cultural knowledge (process of understanding the key aspects of a group’s culture), cultural skills (ability to collect relevant data for health histories and perform culturally specific assessments), and cultural encounters (process that encourages one to engage directly in cross-cultural interactions with people from culturally diverse backgrounds) (AAACN, 2013). Decision-Support Tools – A plan or guide for the assessment and management of a clinical problem to reduce the risk of omission and increase the predictability of desired clinical outcomes. Protocols, guidelines, or algorithms can serve as decision-support tools. Decision tools must incorporate unique patient needs, situations, and preferences. These guides are developed using scientifically valid and documented clinical principles and resources, clinical experience, and the needs of the setting in which they are used. They may be in hard copy or computerized format. Clinical review of the tools should occur annually and revised as needed. Education Process – Systematic planned course of action between and among professionals and patients to develop or expand health care knowledge and/or skills; it is a teaching-learning process among participants. Electronic Medical Record – A secure, real-time, pointof-care, patient-centric documentation system of patient care, services, and status that serves as an information resource for clinicians. Engagement in Health Care – Active and/or proactive behaviors patients need to engage in to obtain the greatest benefit from available health care services. Environment – A complex interrelationship of factors external to the organization and those within the health care organization that surround the patient/population and affects care delivery services. Ergonomics – The scientific discipline concerned with the interactions between humans and other elements of a system, and the profession that applies theory, principles, data, and methods to system design to optimize human well-being and overall system performance (International Ergonomics Association, 2010). Ethics – A philosophical framework for examining values as they relate to human behaviors: how behaviors are viewed as right or wrong, good or bad, and is concerned with both motives and outcomes of actions and/or decisions. Evidence-Based Practice – The conscientious, explicit, and judicious use of current best scientific evidence in making and implementing decisions addressing care and services for patients and populations; nurses utilize research and clinical knowledge and expertise. Expected Outcomes – Anticipated results of health care treatments and/or services delivered to patients and/or populations seen as desirable, measurable, and observable behaviors.

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GLOSSARY Family – The patient identifies family members in her or his own terms that may include individuals related by blood, marriage, or in self-defined relationships. (This definition is intended to include the family in nursing care as appropriate. It is not intended as a legal definition of family.) Hazardous Conditions – Any set of circumstances (exclusive of the disease, disorder, or condition for which the patient is undergoing care, treatment, and services) defined by the organization that significantly increases the likelihood of a serious adverse outcome. Health Care Team – Includes patients, caregivers, and/or population members as well as providers within and across health care systems who partner in developing and implementing plans of care that improve health. Health literacy – Degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (U.S. Department of Health and Human Services, 2000). Institutional Review Board (IRB) – A group of professionals convened by research institutions to ensure protection of rights and welfare of human research subjects participating in research conducted under their auspices. IRBs make an independent determination to approve, modify, or disapprove research protocols based on whether human subjects are protected adequately, as required by federal regulations and local institutional policy. Interprofessional Team – A group of individuals from different disciplines working and communicating with each other, providing knowledge, skills, and attitudes to augment and support the contributions of others. Nursing-Sensitive Indicators – Those indicators that capture care or its outcomes most affected by nursing care (Heslop & Lu, 2014). Outcomes Measurement – The collection and analysis of data using predetermined outcomes indicators for the purposes of making decisions about health care. Patient – Recipient of nursing practice. The term patient provides consistency and brevity, bearing in mind other terms such as client, individual, resident, family, groups, communities, or populations might be better choices in some instances. When the patient is an individual, the focus is on the health state of the unit as a whole or the reciprocal effects of the individual’s health state on others. When the patient is a community or population, the focus is on personal and environmental health and the health risk(s) of the community or population. Performance Improvement – Systematic analysis of the structure, processes, and outcomes within health care systems for improving the delivery of care and outcomes. Plan of Care – A written set of actions developed by the interprofessional team, outlining the care provided to an individual/family/population to resolve/support health care issues identified through assessment. It guides the ongoing provision of care and assists in the evaluation of that care. Population Health Management – Encompasses the ability to assess the health needs of a specific population; implement and evaluate interventions to improve the health of that population; and provide care for patient(s) in the context of the culture, health status, and health needs of the population(s) of which that patient is a member.

Quality Improvement – A systematic and continuous action leading to measurable improvement in health care services and/or the health status of targeted patient groups. Quality of Care – The degree to which ambulatory care nursing and health services for individuals, groups, and populations increase the likelihood of achieving desired health outcomes and are consistent with current professional knowledge Reflective Practice – Thinking about or reflecting on what you do. “Reflective practice is an active, dynamic actionbased and ethical set of skills, placed in real time and dealing with real, complex and difficult situations” (Moon, 1999). AUTHOR: Page number needed for direct quote. Registered Nurse – An individual nurse registered or licensed by a state, commonwealth, territory, government, or other regulatory body to practice as an RN (ANA, 2015). Safe – Avoiding injuries to patient(s) and/or population(s) from the care intended to help them. Self-Efficacy – A person’s confidence in his or her ability to carry out behaviors necessary to achieve the desired health goal. Standard – Authoritative statements developed and disseminated by a professional organization or governmental or regulatory agency that enables the evaluation of the quality of practice, services, research, or education. Standards of Practice – Authoritative statements that describe a competent level of nursing care as demonstrated by the nursing process (ANA, 2015). Standards of Professional Performance – Authoritative statements that describe a competent level of behavior in the professional nursing role (ANA, 2015). Telecommunications – Use of the telephone, Internet, interactive video, remote sensory devices, or robotics to transmit information from one site to another. Telehealth – The delivery, management, and coordination of health services that integrate electronic information and telecommunications technologies to increase access, improve outcomes, and contain or reduce health care costs. Telehealth is an umbrella term used to describe the wide range of services delivered across distances by all health-related disciplines. Telehealth Nursing – Delivery, management, and coordination of care and services provided via telecommunications technology within the domain of nursing; encompassing practices that incorporate a vast array of telecommunications technologies (telephone, fax, electronic mail, Internet, video monitoring, and interactive video) to remove time and distance barriers for the delivery of nursing care. Unlicensed Assistive Personnel – Unlicensed individual who is trained to function in an assistive role to the licensed nurse in the provision of patient/client activities as delegated by the nurse. Virtual Health Care – Electronically enabled care services, including clinician-to-clinician, provider-topatient, and consumer-driven interactions. This definition encompasses a range of terminologies including telemedicine, telehealth, e-health, and mobile health (Lefar, 2015). Wellness – Integrated, congruent functioning aimed toward reaching one’s highest potential (ANA, 2015).

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Additional Readings Agency for Healthcare Research and Quality. (2002). AHRQ’s patient safety initiative: Building foundations, reducing risk. 2002. Rockville, MD: Author. Agency for Healthcare Research and Quality. (2002). The impact of working conditions on patient safety. AHRQ Pub. No. 03P003. Rockville, MD: Author. Agency for Healthcare Research and Quality. (2009). National quality measures clearinghouse. Rockville, MD: Author. Agency for Healthcare Research and Quality. (2006). National quality measures clearinghouse. Rockville, MD: Author. American Academy of Ambulatory Care Nursing (AAACN). (2010). Scope and standards of practice for professional ambulatory care nursing (8th ed.). Pitman, NJ: Author. American Academy of Ambulatory Care Nursing (AAACN). (2011). Position statement: The role of the RN in ambulatory care. Nursing Economic$, 29(2), 96, 66. American Academy of Ambulatory Care Nursing (AAACN). (2012). Position statement: The role of the RN in ambulatory care. Nursing Economic$, 30(4), 233-239. American Association of College of Nurses (AACN). (2014). Doctor of nursing practice (DNP) talking points. Retrieved http://www.aacn.nche.edu/leading-initiatives/dnp/dnp-toolkit/DNP-Talking-Points.pdf American Association of Critical Care Nurses. (2005). Standards for establishing and sustaining health work environments. Retrieved from http://www.aacn.org/WD/HWE/Docs/Exec Sum.pdf American Nurses Association (ANA). (1991). Ethics and human rights position statement: Nursing and the patient selfdetermination acts. Silver Spring, MD: Author. American Nurses Association (ANA). (2001). Code of ethics with interpretive statements. Silver Spring, MD: Author. American Nurses Association (ANA). (2004). Nursing scope and standards of practice. Silver Spring, MD: Author. American Nurses Association (2010). Nursing scope and standards of practice (2nd ed.). Silver Spring, MD: Author. American Nurses Association (ANA). (2004). Scope and standards for nurse administrators. Silver Spring, MD: Author. American Nurses Association (ANA). (2009). Nursing: A common thread amongst all nurses. Nursing’s social policy statement (2nd ed.). Silver Spring, MD: American Nurses Association. American Nurses Credentialing Center. (2013). Magnet® application manual. Silver Spring, MD: Author. Association of Operating Room Nurses (AORN). (2006). Standards, recommended practices and guidelines. Denver, CO: Author. Baird, M., Blount, A., Brungardt, S., Dickinson, P., Dietrich, A., Epperly, T., … DeGruy, F. (2014). Joint principles: Integrating behavioral healthcare into the patient-centered medical home. Annals of Family Medicine, 12(2), 183-185. Berwick, D., & Joshi, M.S. (2004). Healthcare quality and the patient. In S. Ransom, M. Joshi, & D.B. Nash (Eds.), The healthcare quality book vision, strategy and tools. Chicago, IL: Health Administration Press; Washington, DC: AUPHA Press. Bhattacharya, R., Shen, C., & Sambamoorthi, U. (2014). Depression and ambulatory care sensitive hospitalizations among Medicare beneficiaries with chronic physical conditions. General Hospital Psychiatry, 36(5), 460-465. Bodenheimer, T., Ghorob, A., Willard-Grace, R., & Grumbach, K. (2014). The 10 building blocks of high-performing primary care. Annals of Family Medicine, 12(2), 166-171. Buchsel, P.C., & Yarbro, C.H. (2005). Oncology nursing in the ambulatory setting (2nd ed.). Sudbury, MA: Jones and Bartlett. Cusack. G., Jones-Wells, A., & Chisolm, L. (2004). Patient intensity in an ambulatory oncology research center: A step forward for the field of ambulatory care. Nursing Economic$, 22(2), 58-63. Cusack, G., Jones-Wells, A., & Chisolm, L. (2004). Patient intensity in an ambulatory oncology research center: A step forward for the field of ambulatory care – Part III. Nursing Economic$, 22(4), 193-195.

Cutrona, S.L., & Keitz, S.A. (2015). Home is where the patient is: A ground-level perspective on the patient-centered medical home. Medical Care, 53(5), 387-388. Fraher, E., Spetz, J., & Naylor, M. (2015). Nursing in a transformed healthcare system: New roles, new rules. Retrieved from http://ldi.upenn.edu/brief/nursing-transformed-health-caresystem-new-roles-new-rules Freund, T., Campbell, S.M., Geissler, S., Kunz, C.U., Mahler, C., Peters-Klimm, F., & Szecsenyi, J. (2013). Strategies for reducing potentially avoidable hospitalizations for ambulatory care-sensitive conditions. Annals of Family Medicine, 11(4), 363-370. Garrett, M. (2009) Understanding medical home a new opportunity for case managers. Professional Case Management, 14(1), 3-5. Gibson, O.R., Segal, L., & McDermott, R.A. (2013). A systematic review of evidence on the association between hospitalizations for chronic disease related ambulatory care sensitive conditions and primary healthcare resourcing. BMC Health Services Research, 13, 336. Goleman, D. (1995). Emotional intelligence. New York, NY: Bantam Books. Goleman, D. (1998). Working with emotional intelligence. New York, NY: Bantam Books. Griffin, K.F., & Swan, B.A. (2006). Linking nursing workload and performance indicators in ambulatory care. Nursing Economic$, 24(1), 41-44. Haas, S., Swan, B.A., & Haynes, T. (2013). Developing ambulatory care RN competencies for care coordination and transition management. Nursing Economic$, 31(1), 44-43. Haas, S.A., Gold, C.R., & Androwich, I. (1997). Identifying issues in nursing workload. Viewpoint, 19(2), 8-9. Haas, S.A., & Hackbarth, D.P. (1995). Dimensions of the staff nurse role in ambulatory care: Part II – Comparisons of role dimensions in four ambulatory settings. Nursing Economic$, 13(3), 152-165. Haas, S.A., & Hackbarth, D.P. (1995). Dimensions of the staff nurse role in ambulatory care: Part IV – Developing nursing intensity measures, standards, clinical ladders and QI programs. Nursing Economic$, 13(5), 285-294. Haas, S.A., & Swan, B.A. (2014). Developing the value proposition for the role of the RN in care coordination and transition management in ambulatory care settings. Nursing Economics$, 32(2), 70-79. Hertz, A.R. (Ed.). (2011). Pediatric nurse telephone triage: A companion to pediatric telephone protocols. Elk Grove Village, IL: American Academy of Pediatrics. Hinshaw, A.S. (2006). Keeping patients safe - transforming the work environment of nurses. Nursing Administration Quarterly, 30(4), 309-320. Hysong, S.J., Knox, M.K., & Haidet, P. (2014). Examining clinical performance feedback in patient-aligned care teams. Journal of General Internal Medicine, 29(2), S667-A674. Institute of Medicine (IOM). (2006). Improving the quality of healthcare for mental and substance-use conditions. Washington, DC: National Academy Press. Institute of Medicine (IOM). (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academy Press. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2005). Improving organization performance. Joint Commission on Accreditation of Healthcare Organizations manual. Chicago, IL: Author. Joint Commission on Accreditation for Healthcare Organizations (JCAHO). (2006). Patient safety goals for ambulatory care facilities. Chicago, IL: Author. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2006). Standards for ambulatory care and officebased surgery. Chicago, IL: Author. Jones, A., Cusack, G., & Chisholm, L. (2004). Patient intensity in an ambulatory oncology research center: A step forward for the field of ambulatory care – Part II. Nursing Economic$, 22(3), 120-123.

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Additional Readings Katz, A., Martens, P., Chateau, D., Bogdanovic, B., & Koseva, I. (2014). Do primary care physicians coordinate ambulatory care for chronic disease patients in Canada? BMC Family Practice, 15, 148. Kayingo, G., Kidd, V.D., Gilani, O., & Warner, M. (2015). Primary care teams, composition, roles, and satisfaction of pa students during primary care rotations. The Journal of Physician Assistant Education, 26(2). 88-93. King, D. (2005). Development of core competencies for infection prevention and control. Nursing Standard, 19(41), 50-54. Kitson, A. (2001). Approaches used to implement research findings into nursing practice: Report of a study tour to Australia and New Zealand. International Journal of Nursing Practice, 7(6), 392-405. Kris-Etherton, P.M., Akabas, S.R., Bales, C.W., Bistrian, B., Braun, L., Edwards, M.S., … & Van Horn, L. (2014). The need to advance nutrition education in the training of healthcare professionals and recommended research to evaluate implementation and effectiveness. American Journal of Clinical Nutrition, 99(Suppl.), 1153S-1166S. Lefar, S. (2015). What’s real in virtual health? Retrieved from www.sg2.com/health-care-intelligence-blog/2015/03/ whats-real-in-virtual-health/ Lubbe, J.C., & Roets, L. (2014). Nurses’ scope of practice and the implication for quality nursing care. Journal of Nursing Scholarship, 46(1), 58-64. Martin-Misener, R., Harbman, P., Donald, F., Reid, K., Kilpatrick, K., Carter, N., & DiCenso, A. (2015). Cost-effectiveness of nurse practitioners in primary and specialized ambulatory care: systematic review. BMJ Open, 5(6), e007167. Maxwell, J.C. (2005). The 360-degree leader: Developing your influence from anywhere in the organization. Nashville, TN: Thomas Nelson, Inc. McClendon, K.S., Malinowski, S.S., Pitcock, J.J., Brown, M.A., Davis, C.S., Sherman, J.J., … Warrington, L.E. (2014). A multipreceptor approach to ambulatory care topic discussions. American Journal of Pharmaceutical Education, 78(4), 77. Melnyk, B.M., Fineout-Overholt, E., Gallagher-Ford, L., & Kaplan, L. (2012). The state of evidence-based practice in US nurses: Critical implications for nurse leaders and educators. The Journal of Nursing Administration, 42(9), 410-417. Melnyk, B.M., Fineout-Overholt, E., Stillwell, S.B., & Williamson, K.M. (2010). Evidence-based practice: Step by step: The seven steps of evidence-based practice. American Journal of Nursing, 110(1), 51-53. Morton, S., Shih, S., Winther, C., Tinoco, A., Kessler, R., & Scholle, S.H. (2015). Health IT - enabled care coordination: A national survey of patient-centered medical home clinicians. Annals of Family Medicine, 13(3), 250-256. Nelson, K., Sun, H., Dolan, E., Maynard, C., Beste, L., Bryson, C., … Fihn, S.D. (2014). Elements of the patient-centered medical home associated with health outcomes among veterans: The role of primary care continuity, expanded access, and care coordination. Journal of Ambulatory Care Management, 37(4), 331-338. Occupational Safety and Hazards Administration (OSHA). (2002). Protecting workers from job injury. Job Security and Health Safety, 13(3).

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Page, A. (Ed.) (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academies Press. Polit, D.F., & Beck, C.T. (2008). Nursing research: Generating and assessing evidence for nursing practice (8th ed.). Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins. Powers, B.A., & Knapp, T.R. (2006). Dictionary of nursing theory and research (3rd ed.). New York, NY: Springer Publishing Co. Pravikoff, D., Tanner A., & Pierce, S. (2005). Readiness of US nurses for evidenced based practice: Many don’t understand or value research and have had little or no training to help them find evidence on which to base their practice. American Journal of Nursing, 105(9), 40-51. Reinertsen, J.L. (2004). Leadership for quality. In S. Ransom, M. Joshi, & D.B. Nash (Eds.), The healthcare quality book vision, strategy and tools. Chicago, IL: Health Administration Press; Washington, DC: AUPHA Press. Rondinelli, J.L., Omery, A.K., Crawford, C.L., & Johnson, J.A. (2014). Self-Reported activities and outcomes of ambulatory care staff RNs: An exploration. The Permanente Journal, 18(1), 108-115 Salin, S. (2012). Explaining patient satisfaction with outpatient care using data-based nurse staffing indicators. JONA, 42(12), 592-596. Schmitt, B.D. (Ed.) (2015). Pediatric telephone protocols (15th ed.). Elk Grove Village, IL: American Academy of Pediatrics. Senge, P. (1990). The fifth discipline the art and practices of the learning organization. New York, NY: Doubleday. Spader, C. (2009). Cool tools. Nursing Spectrum, 19(11), 20-21. Sullivan, E., & Decker, P. (2005). Effective leadership and management. Upper Saddle River, NJ: Pearson-Prentice Hall. Swan, B.A., & Griffin, K.F. (2005). Measuring nursing workload in ambulatory care. Nursing Economic$, 23(5), 253-260. Swanson, J. (2006). Leadership. In C. Laughlin (Ed.), Core curriculum for ambulatory care nursing (2nd ed.). Pitman, NJ: American Academy of Ambulatory Care Nursing. Trehearne, B., Fishman, P., & Lin, E.H.B. (2014). Role of the nurse in chronic illness management: Making the medical home more effective. Nursing Economic$, 32(4), 178-184. Thompson, D.A. (Ed.) (2012). Adult telephone protocols (3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics. Thorpe, K. (2004). Reflective learning journals: From concept to practice. Reflective Practice, 5(3), 327-343. Tomcavage, J., Littlewood D., Salek, D., &, Sciandra, J. (2012). Advancing the role of nursing in the medical home model. Nursing Administration Quarterly, 36(3), 194-202. U.S. Department of Health & Human Services. (2014). Healthy people 2020 framework. Retrieved from https://www. healthypeople.gov Washington Post (2008, September 10). Patient-centered ‘medical home’ models lag in key areas. Retrieved from http://www.washingtonpost.com/wp-dyn/content/article/ 2008/09/10/AR2008091001482.html Wilson, A., & Hayes, E. (2000). The handbook of adult and continuing education. Hoboken, NJ: John Wiley and Sons.

Scope and Standards of Practice for Professional Ambulatory Care Nursing – 9th Edition – 2017