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1 AMBULATORY NURSES DESCRIPTION OF THEIR SCOPE OF PRACTICE Nursing Research Team Presenters: Sharron Coffie, MSN, RN,CNS-BC, CHFN (PI); Katrina Petrie BSN, RN Olivia Stout, BSN, RN; Kristin Wuest BSN, RN; Marilyn Morris, BSN, RN Katie Klink PhD, RN, CNL; Kathryn Schroeter, PhD, RN, CNE, CNOR Froedtert & Medical College of Wisconsin, Milwaukee, WI, Presentation Objectives Provide historical information of Ambulatory Nursing Practice Describe findings of study of Ambulatory Nursing in Practice Discuss the impact of non-nursing duties on Ambulatory nursing practice Background / Significance: Ambulatory Nursing Practice Nursing practice in the Ambulatory setting requires knowledge integration that will enable nurses to care for complex patient/family care needs, incorporate safety, and comply with regulatory cost effectiveness and Magnet requirements. As an integral component of ambulatory nursing care, RNs must think critically and interpret complex information while they assess, triage, consult, follow-up, collaborate and coordinate care outcomes for patients and families either via telephone triage of brief face-to-face office encounters. Role ambiguity and confusion of the nurse may exist in some ambulatory environments due to high need of medication refills, prior authorizations, making appointments, and other essential, but not necessarily role specific tasks that may be assigned to nurses. Such tasks can alter professional outcomes related to patient satisfaction, quality patient outcomes, patient safety and effective transition of care activities. Evaluating ambulatory nursing practice will help describe the contribution of nursing in the Ambulatory Care setting. 1

2 Why Do Ambulatory Nursing Research? Always starts with questions.. Why do some clinic RNs get paid less? What is the return on investment (ROI) for nursing in ambulatory care? Can RNs make a difference in the cost & outcomes of care Enhance awareness of role, value and impact of nursing practice within the ambulatory clinics Is nurse triage nursing practice? Are nurses operating at top of license? Are ambulatory nurses trained to impact cost & outcomes Changing healthcare environment Decrease length of stay Early appointments in clinics Readmission avoidance High volume of nurse triage (sicker patients) Impact of health literacy Nursing Model Vs. Medical Model Inpatient Outpatient Admission 5 Days Ambulatory 360Days Purpose: The purpose of this study was to describe nurses perception of their nursing practice in an Ambulatory Care setting within clinics associated with an acute care hospital. The original study was done on an inpatient unit. 2

3 Sample/Setting Sample Description/Population: The study group was a convenience sample of registered nurses who provide direct patient care. Setting: 23 ambulatory care clinics in a large Midwestern academic medical center were included in the study. Method/Design: This IRB approved descriptive study used an electronic survey based on the Actual Scope of Nursing (ASCOP) instrument. Written permission obtained from author or original study The instrument included 26 questions scored on a 6-point Likerttype scale. Demographic information was also captured. The dimensions of practice addressed in this instrument were the following: patient safety, assessment /planning, integration/supervision of staff, teaching of patients/families, knowledge updating/utilization, communication/care coordination, and quality of care. Complexity levels of low (base level of practice for any RN, including novice RNs), moderate (requiring more complex interventions that be carried out by all RNs), and high (complex interventions by RNs with considerable experience and BSN training) were identified. Electronic Questionnaire 3

4 Results/Outcomes: Total survey responses where 143. Of those, 123 were fully completed and included in the analysis. Among participants, nearly 70% were BSN prepared. Participants reported: Almost 1/2 of their time doing face-to-face encounters About 1/3 of their time was reported as being spent doing non-nursing work Level 1 complexity: Assessment /planning were a primary task that was associated with. Level 3 complexities: Communication/care coordination and integration/ supervision of staff where associated with. Level 3 Complexity: Communication/care coordination and integration/supervision were significant across all levels of nurse s education background. Education level: reflected the variable of quality for all nurses. How Do RNs Spend Their Time? Almost > 1/2 of their time was spent conducting telephone triage, face-to-face encounters and communication/care coordination. About 1/3 of their time was reported as being spent doing non-nursing work functions such as making appointments, doing prescription refills and completing prior authorizations. How Ambulatory Nurses Spend Their Time 4

5 Level 1 Complexity: Primacy task associated with Assessment /planning Primary Role Function Level 3 complexities: Communication/care coordination and integration/ supervision of staff where associated with Variables of Level 3 Complexity, Communication/care coordination and integration/supervision were significant across all levels of nurse s education background. Level of Education Education level reflected the variable of quality for all nurses. Years of Experience RN Experience 5

6 Job Title RN Position Clinical Application of Results Promotion of Competency Outcome Performance Assessment (COPA) to leadership and with orientation process of RNs Quarterly forums with staff RNs and leadership in the Heart & Vascular Service Line Promotion of PDP in clinic setting Participation in the Ambulatory Business Process Team to evaluate phone triage Continued hallway conversations More research is needed Conclusions/Implications: Ambulatory nurses perception of the value of their core competencies of assessment/planning, care coordination/communication and integration/supervision were significant in this study. More research needs to be done to see how leadership can support nurses to restructure their time from doing non-nursing functions of prior authorizations, medication refills and making appointments. 6

7 Research Dissemination October, 2014 Froedtert & MCW Fall Nursing Research Conference: Poster Presentation March, 2015 Froedtert & MCW Ambulatory Nursing Council May, 2015 Building Bridges: Podium Presentation August, 2015 National Black Nurses Association Conference: Podium presentation 2015 Plan: Nursing Economics publications 2914 FMLH Nursing Fall Research Conference Culver Nursing Research Award 7

8 References American Academy of Ambulatory Care Nursing. (2010). Scope and standards of practice for professional ambulatory care nursing. Pitman, NJ: Arthur. American Academy of Ambulatory Care Nursing, (2011). Scope and standards of practice for professional telehealth nursing (5 th ed.). Pitman, NJ: Arthur. Cupuano T., Bokovy J., Halkins D., Hitchings, K. (2004). Work flow analysis; eliminating non-value- added work. Journal of Nursing Adminstration, 34, D Amour, D., Dubois, C.A, Dery, J., & Clarke, S. (2012). Measuring actual scope of nursing practice: a new tool for nurse leaders. The Journal of Nursing Administration, 42, Mastal, M.F. (2010). Ambulatory care nursing: Growth as a professional specialty. Nursing Economics$, 28, , 275. O Connel, J., Johnson, D., Stallmeyer, J., & Cokingtin, D. (2001). A satisfaction and return-on-investment study of a nurse triage service. American Journal of Managed Care, 7, Nathenson, P., Schafer, L., & Anderson, J. (2007). Relationship of RN role responsibilities to job satisfaction. Rehabilitation Nursing, 32, Needleman J, Kurtzman ET, Kizer KW. (2007). Performance measurement of nursing care: state of the science and the current consensus. Medical Care Research and Review, 64, 10S-43S. Swan, B.A., Conway-Phillips, R., & Griffin, K.F. (2006). Demonstrating the value of the RN in ambulatory care. Nursing Economics, 24, American Academy of Ambulatory Care Nursing. (2010). The role of the registered nurse in ambulatory care position statement. American Academy of Ambulatory Care Nursing. (2006). Core curriculum for ambulatory care nursing (2d ed). Pitman, NJ: Author. Discussion? 8