Practice Setting
Many health care services have shifted from inpatient to ambulatory care settings due to clinical innovation, patient preferences and financial incentives (Abrams, 2018, Burill, 2018). The ambulatory care environment today is diverse; patients receive nursing services, through a combination of in-clinic, virtual care, and digital technologies. Care is often organized through hospital-based outpatient clinics and centers, including:
- Solo/group medical practices
- Ambulatory surgery and medical diagnostic procedure centers
- Telehealth encounters in the virtual environment
- University and community clinics
- Nurse-managed clinics
- Military and VA clinics
- HMOs, and
- Accountable Care Organizations (ACOs)
Development of the Ambulatory Care Nursing Specialty
Origin and early educational growth. Ambulatory care nursing was recognized as a specialty in the late 1970’s. Its origins can be traced to a handful of visionary nursing directors in the Midwest who realized that registered nurses could improve health care in clinic settings. They knew, even then, that realization of this goal would require the development of formal organizational practices and continually growing the nursing knowledge base and evidence.
Those insightful nurse leaders established the first ambulatory care nursing organization, known today as the American Academy of Ambulatory Care Nursing (AAACN), the professional organization representing registered nurses (RNs) practicing in ambulatory, telehealth and other outpatient healthcare settings. Over the course of the several decades, this organization sponsored educational conferences, established standards for the professional practice of ambulatory care clinical and management nursing, assimilated telephone nursing practice into its membership, defined and promoted excellence in leadership, and created a professional home for the burgeoning specialty (AAACN, 2018a).
Maturation: Conceptual growth. In the late 1990’s, AAACN leaders initiated the development of a conceptual framework for ambulatory care nursing. It was a hallmark era that launched true professionalism across the practice specialty (Mastal, 2013, pp.4-5). Nurse organizational leaders conceived that a conceptual framework would serve as a blueprint for ambulatory care nursing practice. Further, it would assist in:
- Designing ambulatory care delivery models;
- Developing testing materials that would identify nurse competencies for specialty certification;
- Developing educational materials.
- Developing orientation programs
- Providing a theoretical structure for research studies (Mastal, 2013, pp.7-8).
In the late 1990s, the first conceptual framework was created by a think tank leader group of AAACN using a nominal group approach (Haas, 1998). It contained two concepts, patient and nurse. The primary purpose was to delineate major areas of ambulatory care nursing practice, knowledge and skills. See Figure 1.
Today’s model looks much different having 3 concepts and a different diagrammatic schema. The current conceptual model expanded the original one, identifying and defining the third concept, environment. The diagram is more inclusive of identifying ambulatory care nursing in the health care environment (Mastal, 2018). See Figure 3. As nursing prepares for the continued shift from hospital-based inpatient care to ambulatory care and the growth in supportive digital technologies, a parallel shift in academic preparation for tomorrow’s workforce needs to occur.
Conceptual Framework: Organizing Structure for Nursing Education and Research
In its 2011 report, the Institute of Medicine identified the need for a profound change in nursing education that would include a “reconceptualization of roles of nurses in a reformed health care system” (p. 4-1). Joint programs between health care organizations and college/university nursing programs were recommended as a strategy to move forward. Since 2011, the health care system has undergone radical shift to ambulatory care settings, however this shift has not catalyzed rapid changes in nursing education or research.
Educational and Research Opportunities. Several authors have described the significant shift that must occur in nursing education to prepare the nursing workforce for current and emerging roles in a redesigned health care system (Niederhauser, V., MacIntyre, R., Garner, C., Teel, C., & Murray, T., 2010, Tanner, 2010, O’Neil, E., 2009). As care shifts to diverse ambulatory settings, nurses must be ready to help lead the transition with strong knowledge and experience in engaging patients and families in self- management of chronic conditions, health, wellness and prevention, as well as symptom management and end of life care.
In order to be successful, education and practice should collaborate to enhance the curricular and clinical experiences to prepare nurses for ambulatory care roles. The AAACN Conceptual Framework could serve as an organizing framework for nursing education, defining the “work” of nurses across ambulatory settings of care, similar to inpatient practice. This would allow faculty to emphasize knowledge development around important concepts and highlight how these concepts are applied in different practice locations and specialties, similar to what happens in inpatient settings.
From a research perspective, this model can also provide an organizing framework to systematically build the evidence around nursing practice, outcomes sensitive to nursing care, and ultimately demonstrate nursing value in ambulatory care settings. In order to demonstrate application of the AAACN Conceptual Framework in education and research, this presentation will provide two brief case study exemplars.
Case Study #1 will describe planning and implementation of a Designated Education Unit (DEU) in a Primary Care setting. This clinical experience was designed as a collaboration between a large academic medical center and regional university. This DEU provides hands-on clinical experience for upper level baccalaureate nursing students utilizing concepts from the AAACN Conceptual Framework.
Case Study #2 will describe the redesign of transitional care services utilizing RN Care Coordinators. This case study will describe redesign hypotheses and research methodology used to evaluate program effectiveness. Aspects of the AAACN Conceptual Framework will be highlighted in the description of the research study.
Conclusion. It is clear that the future of nursing must include strong ambulatory care nursing professional practice. In order to continue the forward momentum, partnerships among academia, research, and practice must emerge. Nursing needs to both create the evidence for professional ambulatory care nursing of the future, as well as educate and train the next generation of nurses in ambulatory care practice.