Ambulatory Playbook: Externs and Delay to Practice New Registered Nurses

Friday, 28 July 2017

Ruth Obregon, EdD, MSN, MBA
Marlene Sarah Ruiz, MA, BSN
Education and Consulting services, Kaiser Permanente, el cajon, CA, USA


The purpose for this project is to discuss the rational behind recruiting and utilizing more registered nurses in the ambulatory care setting through a student externship and transitioning delay to practice registered nurses (RN).

Because of the influx of chronically ill patients with complex co-morbidities into the ambulatory care setting, the need for RNs increased. Many treatments and procedures that were formally in the hospital are now performed in ambulatory care. The background to these changes began with the 1986 passage of a law that created Designated Related Groups (DRG). Payment for procedures and conditions began to be paid prospectively. Each diagnosis and procedure was paid prospectively so that, based on evidence there was a limited amount of time an individual in the inpatient setting could receive a treatment. To keep pace the reimbursement changes, new strategies were required and patient care treatments were moved from the hospital to the outpatient setting requiring RNs. Moreover, the 2010 passage of the Affordable Care Act (ACA) brought many patients into the outpatient setting who without previous health care had complex conditions and therefore needed more multifaceted care.


The method used to meet the need for additional RNs was two-pronged. Begin with schools of nursing and encourage an interest in beginning a career in ambulatory care through student externships and recommending to the organization that hiring new graduates directly into ambulatory care by providing them a new graduate residency transition program (NGRTP). In addition, by recruiting student nurses to experience their externship in ambulatory care a growing interest in beginning a career in ambulatory care evolved.

To encourage the neophyte student RN, a model designed by the director of education engaged the schools to include ambulatory care in their curriculum and provide an optional externship in ambulatory care to interested students. The director of education created a partnership between the school and ambulatory care managers and the birth of the extern model occurred. Each year, the school and healthcare organization, use the model to inform the RN student and assist their consideration of the ambulatory care setting as a viable site for RN practice.

The second option was to recruit the new graduate RN population who were either working underemployed or were not employed at all. The local health care organization standardized the application criteria and to meet the criteria, the applicant must have graduated 1 month to 36 months ago. The first option (encourage the RN student) was easier to implement than the second (hiring the delay to practice RN). First, the delay to practice RN transition was considered more complex than their colleague who immediately transitioned into RN practice. Secondly transitioning any new RN into the ambulatory care setting did not resonate with all managers or educators in the local or other health care settings. Beginning practice in the medical surgical arena was far more acceptable to many RNs than hiring a new RN into an ambulatory care NGRTP.


Against common opinion the local ambulatory care education department conducted 4 DTP-RN transition programs. Of the 4 transition programs, all have remained in ambulatory care, two have been hired into a more acute setting, and one has been promoted to a clinical supervisor position in Primary Care.

The extern program has proven extremely successful, by increasing the number of interested new graduates to enter the specialized field of ambulatory care. Of the 30 externs interviewed, selected to volunteer, and completed the program, as many as 10% chose ambulatory care to practice. Of those who sought inpatient positions, another 10% stated they wanted to transfer into ambulatory care at some point of their career.

The outcome of the externships was an increased interest in ambulatory care as a site for future practice and it as a choice after graduation. Of the 30 externs that were hired from 4 schools 20% found jobs in an outpatient setting. Others stated that they would work in the ambulatory care setting after they worked one year in the inpatient setting.

Conclusion: Over the last 50 years patients and procedures in the ambulatory patient care setting have changed. Patients with complex needs and higher acuity have replaced patients considered the worried well. In addition massive RN retirements are imminent in the ambulatory care setting and the need for registered nurses has increased. Recruiting new graduates through including ambulatory care in nursing curriculum and by providing nursing students with experiences in the outpatient setting has been one organization's remedy for recruiting nurses into a newly recognized specialty of ambulatory care.