The Official Publication and Voice of the American Academy of Ambulatory Care Nursing

Volume 40, Number 2

MARCH/APRIL 2018

Stephanie Witwer and Aleesa M. Mobley

The number of AAACNmembers at the end of2017, marking a new mile-stone and the most mem-bers in the organization’shistory. Thank you for beinga member of AAACN!

We would like to thank the American Academy of Ambulatory Care Nursing (AAACN)for supporting us as representatives for ambulatory care nursing on the National QualityForum (NQF) Emergency Department Transitions of Care project. The NQF, under con-tract with the department of Health & Human Services, provides multi-stakeholder guid-ance on priorities for performance measure development. The quality of health care isdetermined by comparing individual or population performance with a known ideal stan-dard or accepted benchmark.

As representatives of AAACN, we approached our role with this group from the view-point of primary and community care bringing a passion for improving systems of care.It was heartwarming to see the strong support for quality transitions across the continuumfrom so many stakeholder groups. This project had two goals:

Develop a quality measurement framework based on evidence through stakeholder•meetings and research that defines and identifies examples of care quality for transi-tions into and out of the emergency department (ED).Improve person-centered care, value, and cost efficiency by improving the manage-•ment of ED transitions.This work was accomplished through review of the existing literature, input from a

diverse group of stakeholders (physicians, advanced practice nurses, RNs, pharmacists,consumer advocacy groups, emergency medical services, the Joint Commission, insur-ance, electronic health record representatives), and expert advice and analysis from theNQF staff.

Since our task was to develop a framework in an area that has not yet had significantmeasure development, our work product included key domains and information requiredfor quality transitions. Although this may sound abstract, it is quite practical; for example,one domain identified key information that must be transmitted both to and from the EDin order for a safe transition to occur. In the ED, nurses must prepare for the patient’s dis-charge and arrival. Nurses often complete necessary care delivery, access additional allied

continued on page 3

Page 2From the PresidentA Year in Review — Progress and Prospects

Page 4Capturing theEffectiveness of theRegistered Nurse inAmbulatory CareFree Education Activity forAAACN Members

Page 9Emerging Clinical IssuesRe-Emergence of Syphilis andRecognition in the AmbulatoryCare Setting

Page 10Health Policy UpdateLegislative Efforts to Curb theOpioid Epidemic

Page 12Series on LeadershipA Voice for Ambulatory CareNurses: Creation of anAmbulatory Care ProfessionalPractice Council

Page 14Telehealth Trials & TriumphsThe Patient’s Story

2 ViewPoint MARCH/APRIL 2018

TA Year in Review —

Progress and ProspectsThis time last year I began the role of AAACN President

looking forward to ensuring that AAACN had another success-ful year. With the help of you, the owners, customers, andworkforce of the organization, the Board of Directors (BOD),our wonderful Chief Executive Officer (CEO), and colleagues atAnthony J. Jannetti, Inc. (AJJ), we have indeed had a successfulyear. In this final message as President, I will share our accom-plishments and take a brief look at the future.

Progress To meet the needs of members, provide up-to-date infor-

mation and support, advance practice, and create opportunities for members to sharetheir expertise, 4 organizational teams have been formed or rejuvenated. One is theLegislative Team, which is tasked with keeping members updated and informed ofimportant policies and issues related to ambulatory care nursing. Another is the NurseSensitive Indicator (NSI) Team, which will provide updates and information on the devel-opment process and progress in the use of NSIs. The Opening Reception/Silent AuctionTeam will work to organize a wonderful evening reception, perfect for introductions, net-working, and fun, to start off our annual conference. And finally, a Nurse Executive Teamwas also formed this year, comprising members who hold nurse executive positions. Thefocus of this group is to explore the needs and facilitate the success of nurse leaders inthe ambulatory care arena.

I have other exciting news to share on a variety of fronts. We have begun to revampthe AAACN website to modernize it and make it more user friendly. Stay tuned as thesechanges take place. Another change this year illustrating our growth is the decision toupdate our peer-reviewed newsletter. ViewPoint will not only be getting a new look, butwill also be provided in a digital format. Evidence suggests that the nurse role in CareCoordination and Transition Management (CCTM) is critical to quality care and positiveoutcomes throughout the healthcare arena. To help broaden understanding and execu-tion of this important role across the continuum, AAACN will be convening an invitation-al CCTM Summit of nursing and other healthcare leaders in May.

Major resources released this past year include the Ambulatory Care Registered NurseResidency Program, the Preceptor Guide for Ambulatory Care Nursing, and the AmbulatoryCare Nursing Orientation and Competency Assessment Guide. In addition to the soon-to-be-released revised Scope and Standards of Practice for Professional Telehealth Nursing,work is in progress to identify resources to meet the telehealth education needs of ourmembers. Two major projects are well underway, the revision of the Core Curriculum forAmbulatory Care Nursing and the Care Coordination and Transition Management CoreCurriculum. Indeed, we are making great progress on our strategic goals — serving ourmembers, expanding our influence, and strengthening our core.

This past fall, the bylaws were updated and this included changes to make theprocess for selection of the AAACN President and BOD more transparent. AAACN mem-bership (11% increase) and conference attendance this past year was the highest everand has led to financial surplus and security for the organization. Because we are in a fis-cally sound position and all evidence points to a continued positive trend, the BOD hasmade the decision to reinvest some of that capital in the growth and development of theorganization. We have doubled the CEO hours, an investment that will allow greateropportunities and accomplishments. Along with approving an increase in AJJ staff hours,

Reader ServicesAAACN ViewPointAmerican Academy of Ambulatory Care NursingEast Holly Avenue, Box 56Pitman, NJ 08071-0056(800) AMB-NURSFax: (856) 589-7463Email: aaacn@aaacn.orgwww.aaacn.org

AAACN ViewPoint is a peer-reviewed, bi-monthly publication that is owned and pub-lished by the American Academy ofAmbulatory Care Nursing (AAACN). It is dis-tributed to members as a direct benefit ofmembership. Postage paid at Bellmawr, NJ,and additional mailing offices.

AdvertisingContact Tom Greene, AdvertisingRepresentative, (856) 256-2367.

Back IssuesTo order, call (800) AMB-NURS or(856) 256-2350.

Editorial ContentAAACN encourages the submission of newsitems and photos of interest to AAACN mem-bers. By virtue of your submission, you agreeto the usage and editing of your submissionfor possible publication in AAACN's publica-tion, online, and in other promotional andeducational materials.

For manuscript submission information,copy deadlines, and tips for authors, pleasedownload the Author Guidelines andSuggestions for Potential Authors availableat www.aaacn.org/ViewPoint. Please sendcomments, questions, and article sugges-tions to Managing Editor Sarah Black atsarah.black@ajj.com.

AAACN Publications andProductsTo order, visit www.aaacn.org.

ReprintsFor permission to reprint an article, call(800) AMB-NURS or (856) 256-2350.

SubscriptionsWe offer institutional subscriptions only. Thecost per year is $80 U.S., $100 outside U.S.To subscribe, call (800) AMB-NURS or (856)256-2350.

IndexingAAACN ViewPoint is indexed in theCumulative Index to Nursing and AlliedHealth Literature (CINAHL).

© Copyright 2018 by AAACN. All rightsreserved. Reproduction in whole or part, elec-tronic or mechanical without written permissionof the publisher is prohibited. The opinionsexpressed in AAACN ViewPoint are those of thecontributors, authors and/or advertisers, and donot necessarily reflect the views of AAACN,AAACN ViewPoint, or its editorial staff.

Publication Management is provided by Anthony J. Jannetti, Inc., which is accreditedby the Association Management Company

Institute. continued on page 3

Liz Greenberg

WWW.AAACN.ORG 3

we have also approved an additional full-time support staffposition. These staff changes have already made life easierin a variety of ways, including formatting of reports, com-munication, conference calls, webinars, and project assis-tance for task forces. SIG leaders and AAACN representa-tives and members who have been looking for informationand support have already seen a positive difference.

One great accomplishment of the past year was fillingthe CEO position. We had a difficult time finding the rightperson — someone with extensive organizational experi-ence and acumen, and an understanding of nursing. Afteran extended search by AAACN and AJJ, the BOD isextremely confident that the right person was appointedto this important position: our very own Linda Alexander,who served as AAACN’s Director of Association Services.

Prospects AAACN is clearly thriving, largely because of members

such as those of you reading this message. Ambulatorycare nursing has been, and will continue to be, in the spot-light and continuing to evolve. With this comes continuedgrowth, increasing demands for new and updatedresources, shared expertise, and professional collaboration.Managing these demands requires attention to policy,finance, member input, leadership and volunteer needs,and staff time and attention. Luckily, AAACN is maintainingstrong and expert leadership in both our managementservices and the incredible nurse members/leaders. Thus, Iam sure our new challenges will continue to be met andwill spur even further growth of the organization.

It has been an incredible honor to serve this organiza-tion as President. I look forward to serving AAACN in otherroles in the future. In May 2018 at our 43rd AnnualConference in Orlando, Florida, it will be with great confi-dence and optimism that I hand the reins over to our newPresident for 2018-2019, Kathy Mertens, and our new BOD.

Liz Greenberg, PhD, RN-BC, C-TNP, CNE, is Associate ClinicalProfessor, Northern Arizona University, Tucson, AZ

4262 E. Florian Avenue, Mesa, AZ 85206www.lvmsystems.com

Corporate members receive recognition in ViewPoint, on AAACN's website, and in various conference-related publications, as well as priority booth placement at AAACN's Annual Conference. For more information about Corporate Member benefits and fees, please contact Marketing Director Tom Greene at tom.greene@ajj.com or 856-256-2367.

Corporate Members

11161 Overbrook Road, Leawood, KS 66211www.nhanow.com

healthcare contacts, and allocate healthcare resources inorder for smooth and safe transitions of care to take place.The desire by NQF for the presence of nursing at the tableduring quality measure deliberation and sustained interdis-ciplinary collaboration throughout all levels of the qualitymeasurement development process revealed the merits ofthis robust undertaking by the NQF and the importance ofincluding nursing’s voice.

We encourage our AAACN colleagues to step up to theplate when opportunities arise to serve on local, state,regional, or national groups. Our nursing tradition of advo-cacy for patients and families and understanding of sys-tems provides a unique and important contribution as dif-ficult healthcare issues are debated. Your voice is critical.

Stephanie Witwer, PhD, RN, NEA-BC, is Nurse Administrator,Primary Care, Mayo Clinic, Rochester, MN. She may be contactedat witwersg@gmail.comAleesa M. Mobley, PhD, APN, CPHQ, is Adult Nurse Practitionerand Adjunct Assistant Professor, Rowan University, Glassboro, NJ.

View the final report athttp://www.qualityforum.org/Publications/2017/08/Emergency_Department_Transitions_of_Care_-

_A_Quality_Measurement_Framework_Final_Report.aspx

National Quality Forumcontinued from page 1

650 S Exeter Street, Baltimore, MD 21202www.waldenu.edu

Welcome New AAACN StaffPlease welcome our new Director of

Association Services, Jennifer Stranix.Jennifer has spent the last 20 years in theassociation industry, working directly with avolunteer Board of Directors and managingall aspects of daily association operations.

8476 E. Otera Lane, Centennial, CO 80112www.cleartriage.com

2 Miranova Place, Columbus, OH 43215www.covermymeds.com

Instructions for Continuing NursingEducation Contact Hours

Capturing the Effectiveness of theRegistered Nurse in Ambulatory

Care

Deadline for Submission: April 30, 2020

AMBJ1802

To Obtain CNE Contact Hours1. For those wishing to obtain CNE contact

hours, you must read the article and com-plete the evaluation online in the AAACNOnline Library. ViewPoint contact hours arefree to AAACN members.

• Visit www.aaacn.org/library and log in usingyour email address and password.

• Click ViewPoint Articles in the navigation bar. • Read the ViewPoint article of your choosing,

complete the online evaluation for that arti-cle, and print your CNE certificate. CNEtranscripts can be found under “myAccount.”

2. Upon completion of the evaluation, a certifi-cate for 1.2 contact hour(s) may be printed.

FeesMember: FREE Regular: $20

Learning OutcomeAfter completing this learning activity, the

learner will be able to describe the role of a regis-tered nurse practice coordinator (RNPC) demon-strating improvement in quality, safety, and regu-latory compliance in the ambulatory care setting.

Learning Engagement ActivityReview the AAACN Position Statement on the

role of the Registered Nurse at https://www.aaacn.org/sites/default/files/documents/PositionStatementRN.pdfThe author(s), editor, editorial board, content reviewers, and

education director reported no actual or potential conflict ofinterest in relation to this continuing nursing education article.This educational activity is jointly provided by Anthony J.

Jannetti, Inc. and the American Academy of Ambulatory CareNursing (AAACN).Anthony J. Jannetti, Inc. is accredited as a provider of contin-

uing nursing education by the American Nurses CredentialingCenter’s Commission on Accreditation.AAACN is a provider approved by the California Board of

Registered Nursing, provider number CEP 5366. Licensees in thestate of California must retain this certificate for four years afterthe CNE activity is completed.This article was reviewed and formatted for contact hour cred-

it by Rosemarie Marmion, MSN, RN-BC, NE-BC, AAACNEducation Director.

4 ViewPoint MARCH/APRIL 2018

Capturing the Effectiveness of theRegistered Nurse in AmbulatoryCare

With the enactment of the PatientProtection and Affordable Care Act(PPACA, 2010), millions of consumerswho did not have access to healthcare in the past are now able to accessthe healthcare system. According to astudy conducted by the Kaiser FamilyFoundation (2014), an estimated 57%of previously uninsured private planenrollees would gain coverage underthe ACA law. Because of the increasednumber of eligible insured individuals,healthcare organizations are nowpressed to use their current staff morecreatively to meet the needs of agrowing population presenting withmore complex diseases. To care formore patients with fewer resources, itis imperative that all healthcare practi-tioners be allowed to practice to thefull extent of their education andlicensure. All clinical staff should beused in a cost-efficient manner thatelicits the desired patient outcomes.Therefore, it is essential to review cur-rent care delivery models, includingthe function of a RN in the ambulatorycare setting, and explore ways tomore fully implement the role.

To increase negotiating leverage,healthcare systems across the countryare acquiring independent physicianpractices at an astounding rate.According to Kuramoto (2014), con-solidation and mergers with similarpractices is a viable strategy for deal-ing with the new challenges emergingin health care. Practice mergers devel-op to attain better economies of scalewith group purchasing power,improved affordability of informationtechnology, increased market pres-ence, and better negotiation withinsurance payers related to their keystrengths. As a result of these mergers,practices are often scattered acrosslarge geographic areas, which chal-lenges organization leaders when allo-cating clinical support and supervisionto ensure patient safety and qualitycare.

Inadequate supervision of clinicalsupport staff is a patient safety issuethat plagues many healthcare leaderswho are tasked with managing a largegeographic area. According to Haasand Gold (1997), it is important toexamine the role of supervision whenfacilitating change and promoting thesuccess of care delivery models thatuse unlicensed assistive personnel inambulatory care. In most ambulatorycare clinic settings, clinical supportstaff supervision and training was theresponsibility of the doctor and, inmany cases, nonclinical operationsmanagers. Often ambulatory careclinics are staffed with medical assis-tants with LVNs and RNs being ascarce commodity. The disparity inthis care delivery model is the absenceof the RNs and any accountability forclinical support staff competency,including any required compliancewith environment of care standards.

The Institute of Medicine’s (IOM)Future of Nursing Report (2011) chal-lenges nurses to partner with otherhealthcare professionals in leading thetransformation of health care by bothrecognizing and using the RN to thefull extent of their education andlicensure. According to Mastal andLevine (2012), the capabilities of theRN often are unseen, undervalued,and underutilized in many health careorganizations. The authors also wrotethat “whenever [an] RN is present,there is an increase in patient satisfac-tion, enhanced documentation,improved collaboration betweenphysicians and nurses, and also theimproved health and well-being of thepatient when directing them to theappropriate level of care” (p.295).

According to the AmericanAcademy of Ambulatory CareNursing’s (AAACN) PositionStatement on the Value of theRegistered Nurse in Ambulatory Care(2017), ambulatory care nursing is aunique realm of specialized nursing

Continuing NursingEducationEEdEduEducEducaEducatEducatiEducatioEducationEducation

FREE

WWW.AAACN.ORG 5

practice. The RN is uniquely qualifiedto influence the organizational stan-dards related to patient safety andcare delivery in the outpatient setting.Ambulatory care nurses are knowl-edgeable professionals who functionwell in a multidisciplinary, collabora-tive practice environment. RNs alsoutilize critical thinking skills to inter-pret complex information and guidepatients and families back to healthand well-being (Swan, Conway-Phillips, & Griffin, 2006). The PositionStatement (AAACN, 2017) also statesthat RNs enhance patient safety andare essential and irreplaceable in theprovision of patient care services in anambulatory care setting.

Methods The purpose of this evidence-

based practice project was to evaluatethe effectiveness of the RegisteredNurse Practice Coordinator (RNPC), anew RN role created for the ambulato-ry care setting in our organization.The role was created in 2014 after areview of baseline data showed varia-tions in practice across the areaswhere RN support was not present.This baseline data included environ-ment of care audits, significant eventsin the clinics, and discussion with theambulatory care nursing team. Duringthe timeframe of this project, therewere two RNPCs assigned to 20 clin-ics. These clinics were a combinationof primary, pediatric, and specialtycare.

The overall RNPC role expectationwas to provide clinical supervisorysupport across a large geographicregion of ambulatory care practiceswithin an academic health system.The RNPC was created to be responsi-ble for assisting with clinical quality,staff education, and clinical resourcesupport for the clinical staff. The RNPCis expected to collaborate with theoutpatient department managers,clinical staff, and physicians toenhance quality care by ensuring con-sistent clinical practices as they relateto regulatory standards and institu-tional policies and procedures.Initially, the physicians felt that thecoordinators should participate inpatient care when the clinics wererunning behind schedule; however,

blinded the questionnaires using anumber in place of their name andaggregated the data by analyzing theanswers to each question. Keywordswere entered into a spreadsheet andthose used more than five times byproject participants were selected toidentify themes regarding their per-ception of the RNPC role (availableupon request from the author).

After the investigator presentedthe project to the participants associ-ated with the chosen practices,detailed information was collected onthe role of each practice coordinator,including job description, practice set-ting, work hours, and scope of work.All participants received an informa-tion letter and the appropriate audittool described below.

In order to validate the effective-ness of the new RNPC role, the projectinvestigator created three differenttools that were completed by the par-ticipants. These three tools helped toevaluate the implementation effec-tiveness of the role. The first tool wasthe Self-Evaluation Questionnairecompleted by each RNPC to assess therole (available upon request from theauthor). The second tool was thePractice Coordinator EffectivenessRating Interprofessional ColleagueAssessment questionnaire (see Figure1). This tool focused on gatheringinsights regarding the RNPC role fromthe perspective of the practice man-ager, physicians, ambulatory carenursing department colleagues, andthe RNPC’s immediate supervisor. Thethird tool was the PracticeCoordinator Observation Form (seeFigure 2), which focused on directperformance observations of theRNPC of their job duties and tasks.Using the Practice CoordinatorObservation tool for documentation,direct observations by the investigatortook place while RNPC-A and RNPC-Bperformed quality of care audits. TheRNPCs were observed on two sepa-rate occasions, one-month apart, per-forming quality of care assessmentsand interacting with clinical staff andpractice managers. Specific attentionwas paid to the actual communicationof information to both the practicemanager and staff and their responsesto that information. For example, an

both the nursing and non-clinicalleadership determined that each clinicshould be staffed appropriately tohandle its volume of patients, and theRNPCs should have a specific set ofresponsibilities that did not includedirect patient care.

Under the direction of the ambu-latory care nursing leadership, theRNPCs were, and still are, assigned toa group of clinics based on a staffingindex with an Exertion Number (EN)created to equally assign responsibilityto the RNPC. EN = (total miles fromUCLA x .5) + (total number of clinicalstaff [MA, LVN, RN] x 2). The ENafforded a mathematical balanceacross all clinics by weighing the num-ber of staff against the distance to theclinic from the home office and takinginto account the size of the practice.Based on the number of staff in eachclinic, type of service provided, andthe driving distance from the homeoffice, it was determined that a totalindex number of 150 was suitable as amaximum index per RNPC.Assignment of EN greater than 150proved to be too great a number ofstaff for one RNPC to supervise whileallowing for consistent completion ofjob duties and planned visibility in theclinics. This equated to a 1:9 ratio ofRNPC to ambulatory care clinics. Thejob duties of the RNPC included assist-ing in the development and review ofambulatory care nursing competen-cies, coordinating new-hire orienta-tion, and providing clinical educationas it relates to best practices and/orevidence-based practices in ambulato-ry care.

Thirty clinics were involved in theRNPC evaluation project. Twenty clin-ics had an RNPC—two RNPCs covered10 clinics each—and another 10 clin-ics did not have an RNPC. In additionto the two RNPCs, project participantsincluded five physicians, 20 practicemanagers, five operations directors,one immediate RNPC supervisor, andtwo ambulatory care nursing adminis-trative support personnel. Once IRBapproval was received, project volun-teers, due to their role and associationwith the RNPC role, completed theinformed consents and project ques-tionnaires, returning them to theinvestigator via email. The investigator

6 ViewPoint MARCH/APRIL 2018

unlabeled multi-dose vial of medica-tion was found in the medicationrefrigerator. The RNPC immediatelyinformed the practice manager of thefindings and educated both the man-ager and the staff on the implicationsand actions required to correct thisfinding. The education was acceptedwell by all present and the RNPC wenton to document this occurrence onthe audit tool.

The RNPC position has four jobfunctions: (1) coordination of clinicalstaff, (2) staff education, (3) consult-ing, and (4) performance improve-ment. The coordination role providesassistance with implementation ofnew programs through education andtraining, ensures consistent standardsof care are maintained across ambula-tory care practices, and serves as aclinical resource to the practice man-agers. As staff educator, the RNPCidentifies educational needs based onlow-volume, high-risk outpatient pro-cedures and recognized trends fromquality reports. The consulting rolecollaborates with both practice man-agers and physicians providing direc-tion on executing institutional poli-cies, guidelines and other processesthat affect the clinical support staff.

Among performance improvement(PI) activities conducted by the RNPCare quality of care audits defined asperforming observations, data collec-tion, and evaluation of improvementefforts.

One of these PI activities, done ona monthly basis, is the patient safetystandard audit. The organization’sambulatory care Quality of Care audittool assists the RNPC in monitoringcompliance with the environment ofcare and its regulatory requirements.The tool is used by the RNPC toreview the practice compliance relat-ed to medication storage, infectioncontrol, expired supplies, Point ofCare Testing control performance,and medication refrigerator tempera-ture monitoring. It was adapted fromthe Association for Professionals inInfection Control and Epidemiology(APIC) Infection Control inAmbulatory Care (Friedman &Petersen, 2004) and the Centers forDisease Control and Prevention (CDC)Guidelines for Vaccine Storage andHandling (CDC, 2017). The tool wasused to compare practices with apractice coordinator to those withoutone during the project.

ResultsThe investigator received a total

of 2 responses to the Self Evaluation(100%).Twenty responses to the prac-tice effectiveness tool, were returnedfor a response rate of 70%. After ananalysis of the Self Evaluation respons-es, keywords revealed the RNPC con-sidered the role to be that of an edu-cator, mentor, advisor, coordinator,and change agent, which matchedthe job description and the originalintent of the role. A thematic dataanalysis of the responses to the prac-tice effectiveness tool revealed pat-terns in the keywords used to describethe perceptions of those who workwith the RNPC. The results of thisanalysis indicated clear role delin-eation between the practice managerand the RNPC. The responses revealedthat the RNPCs provided education,regulation supervision, and environ-ment of care assessments thatenhanced the quality of patient care.When comparing the role of theRNPC to the practice manager, theparticipants agreed that the manag-er’s role was more operational and theRNPC role more clinically focused.

Figure 1.Practice Coordinator Effectiveness Rating Tool for Interprofessional Colleague Assessment

Assessment ID # _____________________________________________ Date Completed ____________________________________

Evaluator’s Role ______________________________________________ Practice Location ____________________________________

The purpose of this questionnaire is to gather your perception of the effectiveness of RN Practice Coordinators.Your feedback is appreciated.

Questions

1. What is your view of the role of the RN Practice Coordinator in the ambulatory setting?

2. What is the difference between the Practice Manager and the Practice Coordinator?

3. Describe a time (Give examples) when the RN Practice Coordinator made recommendations and took actions to improve patientsafety

4. How has your experience with the RN Practice Coordinators influenced the decisions that you make regarding patient care?

5. In your opinion, how has the work of the Practice Coordinator influenced the quality of patient safety in your clinic?

Responses/Comments

WWW.AAACN.ORG 7

Figure 2.Practice Coordinator Observation Form

PC ID# _____________________________________________________ Observation Period __________________________________

Position ____________________________________________________ Location ___________________________________________

Evaluator ___________________________________________________ Time _______________________________________________

Rating Scale: E = Exceeds expectations D = Does not meet expectations M = Meets expectations N/O = Not observed

An analysis of the PracticeCoordinator Observation Formrevealed that the RNPC provided sup-port and direction in an area that waspreviously missing in the clinics. TheRNPC excels in providing staff educa-tion, regulatory compliance surveil-lance, and conducting environment ofcare assessments that enhance thequality of patient care. The resultsfrom the tool’s Staff Education com-ponent described how the RNPC wasobserved actively teaching skills toclinical staff. Upon receiving this train-ing, staff reported increased confi-dence in their ability to performassigned tasks, and the improved skillswere validated by the physicians, who

stated that staff had more confidenceand improved task-related perform-ance. Consultation results describedthe RNPC strengths as more clinicallyfocused as evidenced by the followingexample: One respondent answered“Practice Coordinators are an integralpart of the patient care team, and weinclude them in all decisions that mayaffect patient care. It is very helpful tohave an RN available to answer clinicalworkflow questions when trying toimprove efficiency.” The environmentof care audits were compared prior tothe implementation of the new roleand during the next 12 months withthe new RNPC (see Table 1). Theresults underscored the work the

RNPC was doing to improve the envi-ronment of care. For instance, reviewof the infection control standardsrevealed compliance of 61% and 64%in October 2014 prior to the imple-mentation of the RNPC as comparedto 100% after implementation of therole. These findings confirm whatnurse leaders recognized was deficientin the clinics. The RNPC promotedquality care and ensured consistencyin clinical practices, in addition to pro-viding support, leadership, and direc-tion for patient care activities in accor-dance to organizational goals.

Duties and Tasks N/O D M E

Coordination of Clinical Staff

Serves as a resource to ambulatory care managers.

Serves as a liaison when developing processes that assist the clinics and physicians inproviding continuity of care to our patients.

Ensures maintenance of consistent standards of care across the continuum ofambulatory care.

Staff Education

Identifies the educational needs of the patient care staff.

Implements strategies that enable staff to demonstrate clinical competency andprofessional accountability.

Implements competency-based orientation for staff. Discusses findings withappropriate management and provides feedback.

Provides staff education based on identified trends from event reporting. Incollaboration with clinic managers, assists in developing plans of action related toadverse events.

Consultation

Works with ambulatory care leadership to assist with complicated clinical problemsidentified through performance improvement and other processes.

Performance Improvement

Actively provides recommendations to ambulatory care practice leadership; ensuresongoing participation in quality management activities.

Participates in quality studies through data collection.

Makes recommendations and takes actions to improve structure, system, or outcomes.

8 ViewPoint MARCH/APRIL 2018

SummaryThe role of the RNPC has demonstrated that it can

improve quality, safety and regulatory compliance inambulatory care clinics. The data supported the goal of theRNPC’s role effectiveness by providing support for ambula-tory care clinical staff, increasing the visibility of nursingleadership in the remotely located clinics, and deliveringenhanced support for non-clinical managers on clinicalpractice related issues. In addition, the RNPC provides alevel of professional nursing practice in ambulatory care

through standardizing clinical orientation and staff compe-tency validation which, in turn, enhances the safety andquality of care in the clinic environment. This role provideseffective continuity and enhanced relationship buildingacross ambulatory care clinics and the organization.

Quanna N. Batiste, DNP, HCSM, RN, NEA-BC, FABC, is theChief Nursing Officer of Ambulatory Care, UCLA Health, LosAngeles, CA. She may be reached at qbatiste@mednet.ucla.edu

ReferencesAmerican Academy of Ambulatory Care Nursing (AAACN). AAACN

Position Statement: The role of the registered nurse in ambula-tory care. (2017). Nursing Economic$, 30(4), 233-239.

Centers for Disease Control and Prevention (CDC). (2017, May 1).Vaccine Storage and Handling Toolkit. Retrieved fromhttps://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/

Friedman, C., & Petersen, K. (2004). Infection Control in AmbulatoryCare. Sudbury, MA: Jones and Bartlett Publishers.

Haas, S., & Gold, C. (1997). Perspectives in ambulatory care.Supervision of unlicensed assistive workers in ambulatory set-tings. Nursing Economic$, 15(1), 57-59.

Institute of Medicine. (2011). The future of nursing: Leadingchange, advancing health. Colorado Nurse, 111(1), 1-7.

Kaiser Family Foundation Report. (2014). Percentages of uninsuredby state before and after the Affordable Care Act (ACA).American City & County, 129(8), 5.

Kuramoto, R.K. (2014). Specialties: Missing in our healthcare reformstrategies? Journal of Healthcare Management, 59(2), 89-94.

Mastal, M., & Levine, J. (2012). Perspectives in ambulatory care. Thevalue of Registered Nurses in ambulatory care settings: A sur-vey. Nursing Economics$, 30(5), 295-304.

Public Law 111-1 2nd Session Congress. (2010). Patient Protectionand Affordable Care Act.

http://www.gpo.gov/fdsys/pkg/BILLS-111 hr3590enr/pdf/BILLS-111 hr3590enr.pdf

Swan, B.A., Conway-Phillips, R., & Griffin, K.F. (2006).Demonstrating the value of the RN in ambulatory care. NursingEconomic$, 24(6), 315-322.

RNPC Aaverage % compliance for 9 clinics

Group A

RNPC Baverage % compliance for 9 clinics

Group B

No RNPCOct 2014

6 monthsw/ RNPCApril 2015

12 months w/ RNPCOct 2015

No RNPCOct 2014

6 months w/ RNPCApril 2015

12 months w/ RNPCOct 2015

Infection Control 64% 100% 100% 61% 100% 100%

Point Of Care Testing 78% 100% 94% 100% 93% 100%

Medication Safety 62% 100% 98% 63% 100% 98%

Utility Room/ Supplies &Storage 44% 98% 100% 48% 93% 100%

Refrigerators andFreezers 72% 100% 94% 100% 100% 100%

Exam Rooms 86% 93% 96% 69% 91% 98%

Table 1.Results of Environment of Care Audits Reflecting Clinic Compliance Before the RNPC was Implemented and

Clinic Compliance with RNPC Over 1 Year

(October 2014–October 2015)

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Re-Emergence of Syphilis andRecognition in the

Ambulatory Care SettingWhen is the last time you encountered a patient with

syphilis or even considered the need for testing for syphilis?If you work in obstetrics or in a setting where routine test-ing for sexually transmitted infections (STI) is indicated,your answer may be very different than clinicians workingin other ambulatory care clinical settings or specialty prac-tices. The prevalence of syphilis in the United States is ris-ing. The rate of primary and secondary syphilis increased22% between 2011 and 2013 after a 90% decline in thedisease from 1990 to 2000 (Stamm, 2016). The Centers forDisease Control and Prevention (CDC) showed a syphilisrate of 27.4 cases per 100,000 people in 2016, which is upfrom 2015 statistics of 23.2 cases per 100,000 people(CDC, 2017b). Syphilis is a reportable disease across theUnited States, which helps local health departments man-age local statistics and provide data to the CDC for nationalstatistics.

Ambulatory care nurses are well positioned to screenand identify patients at risk for this disease by being mind-ful of the serious sequelae that can occur with untreatedsyphilis. Could the patient in your neurology office withunexplained muscle movements or the patient presentingwith upper respiratory symptoms have syphilis? Value inhealth care is paramount and ordering unnecessary testingmay have clinical and financial implications. However,given the prevalence of syphilis in many of our communi-ties, maintaining appropriate clinical suspicion will requireclinicians to weigh the need for screening with the signifi-cant harm and expense the disease may incur. Syphilisaffects all age groups and racial demographics and, whilecurrently most prevalent among men who have sex withmen, is also found among patients identifying as hetero-sexual (CDC, 2017b). The prevalence of any STI increasesthe risk for other types of STIs. There is a correlationbetween syphilis and HIV infection (CDC, 2017b).

What is Syphilis? Syphilis is an STI and can also be passed from mother

to baby during pregnancy. Risk factors include, but are notlimited to, being infected with other STIs, using illicitdrugs, being a man who has sex with men, living in an areawith high rates of syphilis, and being a sex worker (U.S.Preventive Services Task Force [USPSTF], 2016). There are4 phases of syphilis. The initial stage presents with a small,painless sore to the genital area, but sores may also bepresent on the lips, in the mouth, or anus (USPSTF, 2016).Secondary syphilis can present with a rash or sores on thepalms of the hand or soles of the feet (CDC, 2017a).Systemic symptoms such as headache, enlarged lymph

nodes, fatigue, or sore throat may also be present. Becauseof the vagueness of the systemic symptoms and the factthat these symptoms will resolve even without propertreatment can often delay treatment for patients unsus-pecting of syphilis (USPSTF, 2016). The rash on the palmsof the hands is important to recognize, despite the clinicalsetting, as it is not common to see skin changes in thislocation. Patients with latent syphilis are asymptomatic butable to pass the infection (CDC, 2017a). In the third stageof syphilis, or late-stage syphilis, patients are likely to havemore organ involvement with damaging effects on thebrain, heart, nerves, and joints, to name a few. Paralysisand blindness can occur. At any stage of syphilis, patientsmay experience changes in personality, memory changes,movement disorders, or loss of coordination (USPSTF,2016). Sadly, syphilis can be fatal in patients left untreatedwith late-stage syphilis (USPSTF, 2016)

Screening for syphilis can be done by a simple blooddraw. Penicillin remains the gold standard treatment forsyphilis and the dosage varies depending upon the lengthof exposure. Patients with a stated allergy to penicillinshould be assessed for severity of the allergy to determineif alternative treatments should be explored. A recent studycompared doxycycline/tetracycline to ceftriaxone as sub-stitute options for penicillin and found that ceftriaxonemay be a better alternative for syphilis treatment in thosewith a penicillin allergy (Liu, H., et al., 2017). Treatment forsyphilis should occur in all patient populations, includingthose with congenital syphilis and during pregnancy.Syphilis is associated with increased risk of miscarriage, still-birth, and congenital abnormalities, hence the need forscreening during pregnancy.

Let us not forget the national misfortune that occurredbetween 1932 and 1972, where treatment for syphilis wasintentionally withheld from infected black men, also calledthe U.S Public Health Service Syphilis Study. Penicillin wasdetermined to be the drug of choice for syphilis in 1947 yetthis study continued until 1972. There is now a nationallymandated program providing lifetime medical and healthbenefits to the widows and offspring of the black men whowere affected by this Tuskegee Study (CDC, 2015).

No matter the setting, we have the opportunity to bemindful of syphilis and remember that it is not a disease ofthe past. The CDC reported cases of syphilis in every stateacross our country in 2016. What you can do to be moreaware of syphilis in your community?

ReferencesCenters for Disease Control and Prevention (CDC). (2015). U.S.

Public Health Service Syphilis Study at Tuskegee. Retrieved fromhttps://www.cdc.gov/tuskegee/

Centers for Disease Control and Prevention (CDC). (2017a). Syphilis:CDC Fact Sheet. Retrieved from https://www.cdc.gov/std/syphilis/stdfact-syphilis.htm

Centers for Disease Control and Prevention (CDC). (2017b). 2016Sexually Transmitted Diseases Surveillance. Retrieved fromhttps://www.cdc.gov/std/stats16/tables/24.htm

Liu, H., Han, Y., Chen, X., Bai, L, Guo, S., Wu, P, & Yin, Y. (2017).Comparison of Efficacy of Treatments for Early Syphilis: ASystematic Review and Network Meta-Analysis of Randomized

contiued on page 11

10 ViewPoint MARCH/APRIL 2018

Legislative Efforts to Curbthe Opioid Epidemic

It has been 100 years since the first federal law control-ling the sale and distribution of opiates in the United Stateswas passed in 1914 under the Harrison Narcotics Tax Act(Rettig & Yarmolinsky, 1995). Previously, opioid-contain-ing products were sold directly to the public as patentmedicines, but growing state and local concernaround opioid addiction led the federalgovernment to act. An importantlegal interpretation of theHarrison Act regarding physi-cian prescription of opiateswas made in the SupremeCourt decision Webb vs US(1919). It prevented physi-cians from prescribing opi-ates for maintenance (i.e.,treatment of addiction).

The Vietnam War broughtabout a resurgence in opiate useand increased the visibility of addic-tion. One major purpose of the Comprehensive DrugAbuse Prevention and Control Act of 1970, also known asthe Controlled Substances Act, was to reverse some of thestrictures of the Harrison Act of 1914. The 1970 act sought“to clarify for the medical profession… the extent to whichthey may safely go in treating narcotic addicts as patients.There are relatively few practicing physicians in the U.S.today who treat narcotic addicts because of the uncertain-ty as to the extent to which they may prescribe narcoticdrugs for addict patients” (Rettig & Yarmolinsky, 1995,ch.5, para. 15). This new act recognized addiction as amedical problem requiring treatment and led to theexpansion of methadone clinics in the United States (Rettig& Yarmolinsky, 1995).

Today, buprenorphine (Suboxone) has been pre-scribed by physicians in primary care clinics for 10 years asan alternative to methadone to treat opioid use disorder.The Substance Abuse and Mental Health ServicesAssociation, a branch of the U.S. Department of Health andHuman Services, developed an evidence-based treatmentof opioid use disorder, medication assisted treatment(MAT). MAT is a combination of buprenorphine prescrib-ing with counseling and behavioral therapy (SAMHSA,2016a).

Because it is a partial opioid agonist combined withnaloxone, buprenorphine is safer than methadone, easierto dispense, and, when used in clinic-based primary caresettings, reduces the stigma and increases patient access tobasic medical care in addition to behavioral health and

addiction or chronic pain treatment. Increasing access toprimary care for patients with opioid use disorder is impor-tant because of the high rates of comorbidities in that pop-ulation such as viral hepatitis, human immunodeficiencyvirus infection, and acquired immunodeficiency disease(SAMHSA, 2016a).

The current opioid crisis in the United States requiresimproved access to prevention and treatment options. TheComprehensive Addiction and Recovery Act, signed into

law July 22, 2016, expanded for 5 years the pre-scribing privileges for office-based buprenor-phine treatment clinics to include nurse practi-

tioners and physician assistants (American Societyof Addiction Medicine, n.d.).AAACN recently participated through the Nursing

Community Coalition in sending a letter to Congress insupport of H.R. 3692, the Addiction Treatment AccessImprovement Act. The letter thanks the bill’s authors,Representative Paul Tonko (D-NY) and Ben Ray Lujan (D-NM), for introducing the bill to the House ofRepresentatives. The bill is an amendment to broadenthe Controlled Substances Act, eliminating the 5-yeartime limit and expanding the category of non-physi-cian providers from nurse practitioners (NP) andphysician assistants to include all advanced practiceregistered nurses (APRN) providing care to those suffer-

ing from opioid addictions, namely clinical nurse special-ists (CNS), certified nurse midwives (CNM), and certifiedregistered nurse anesthetists (CRNA). The ability of thesenew categories of APRNs to fully register for MAT will stillbe determined by each state’s specialty scope of practicelaws (Nursing Community Coalition, 2017).

Whereas NPs and CNMs have practice and prescriptiveauthority in 50 states (whether dependent or independ-ent), CRNAs and CNSs face hurdles toward fully practicingwithin their scope in multiple states (National Council ofState Boards of Nursing, 2017). For instance, CNSs haveindependent and dependent prescription authority in 39of the 50 states, with no prescriptive authority in New York,Washington, and Florida (National Association of ClinicalNurse Specialists, 2016). These same 3 states have signifi-cantly increased opioid death rates according to theCenters for Disease Control and Prevention (CDC) (2017a).This potentially expanded practice is a reminder of lastyear’s ViewPoint Health Policy Update column urging allnurses to support the full scope of practice for APRNs tomeet the Institute of Medicine’s Triple Aim goals (Fuller,2016). Knowing the scope of practice laws in your state forregistered nurses and advanced practice nurses and advo-cating at the state level for full scope of practice legislationwill help bring this expanded practice option to all APRNs.

In addition to enacting treatment expansion approvalat the national level, some states are approaching the opi-oid addiction epidemic by limiting supply of prescriptionopioids. “We now know that overdoses from prescriptionopioids are a driving factor in the 15-year increase in opioidoverdose deaths. The amount of prescription opioids soldto pharmacies, hospitals, and doctors’ offices nearlyquadrupled from 1999 to 2010, yet there had not been an

WWW.AAACN.ORG 11

overall change in the amount of pain that Americansreported. Deaths from prescription opioids — drugs likeoxycodone, hydrocodone, and methadone — have morethan quadrupled since 1999” (CDC, 2017b, para. 2). Thelikelihood of developing an opioid use disorder increaseswith each additional day of a person’s first opioid prescrip-tion (Shaw, Hayes & Martin, 2017). Legislation limitingopioid prescriptions started in Massachusetts in 2016, witha 7-day supply limit for first-time opioid prescriptions.According to tracking by the National Coalition of StateLegislatures (NCSL), by August 2017, 24 states had enact-ed some type of legislation limiting opioid prescribing(NCSL, 2017).

One tool that assists providers in safe prescribing is thePrescription Drug Monitoring Program (PDMP), astatewide electronic database to check for a patient’s pre-scription history to help prevent overlapping prescriptionsin the same class. Varying by state, the PDMP is housed bya specified statewide regulatory, administrative or lawenforcement agency. The data from the database is avail-able to individuals, like healthcare providers, who areauthorized under state law to receive the information forpurposes of their profession (U.S. Department of Justice &Drug Enforcement Agency, 2016).

Ninety-one Americans die every day from an opioidoverdose (CDC, 2017b). To address this worst-case sce-nario, all states have expanded public access to the life-sav-ing opioid antidote naloxone. By July 15, 2017, all 50states and the District of Columbia had passed legislationdesigned to improve layperson naloxone access and 40states plus the District of Columbia have passed an over-dose Good Samaritan law that provides some protectionfrom arrest or prosecution for individuals who report anoverdose in good faith (Davis, Chang, Carr, & Hernandez-Delgado, 2017). An excellent resource for learning andteaching patients about opioid overdoses is the SAMHSAOpioid Overdose Toolkit (2016b).

Considering the number of Americans touched by theopioid epidemic, it is likely that regardless of your practicesetting, you work with patients affected by this publichealth crisis. Educating yourself on the national and statelaws and regulation surrounding all aspects of opioids (pro-duction, distribution, prescribing, safety, dispensing, pre-vention, and treatment) will empower you to best serveyour patients and their families. Advocating for laws thatprotect patient health and dignity and implementing newprograms under those laws are as much a part of our workas nurses as is our direct care of patients.

ReferencesAmerican Society of Addiction Medicine. (n.d.). Nurse Practitioners

and Physician Assistants Prescribing Buprenorphine. Retrievedfrom https://www.asam.org/resources/practice-resources/nurse-practitioners-and-physician-assistants-prescribing-buprenorphine

Centers for Disease Control and Prevention (CDC). (2017a). DrugOverdose Death Data. Retrieved from https://www.cdc.gov/drugoverdose/data/statedeaths.html

Centers for Disease Control and Prevention (CDC). (2017b).Understanding the Epidemic. Retrieved fromhttps://www.cdc.gov/drugoverdose/epidemic/index.html

Davis, C., Chang, S., Carr, D., & Hernandez-Delgado, H. (2017).Legal interventions to reduce overdose mortality: Naloxoneaccess and overdose good Samaritan laws. Network for PublicHealth Law. Retrieved from https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf

Fuller, S. Advocacy: Full Scope for Advanced Practice Registered Nurses.ViewPoint, 38(6),12.

Public Law –63rd Congress. (1914). Harrison Narcotics Act. Retrievedfrom http://www.druglibrary.org/Schaffer/history/e1910/har-risonact.htm

National Association of Clinical Nurse Specialists. (2016). CNS Scopeof Practice and Prescriptive Authority Map Retrieved fromhttp://nacns.org/advocacy-policy/policies-affecting-cnss/scope-of-practice/

National Council of State Boards of Nursing. (2017). CNPIndependent Practice Map. Retrieved from https://www.ncsbn.org/5407.htm

National Coalition of State Legislatures. (2017). Prescribing Policies:States Confront Opioid Overdose Epidemic. Retrieved fromhttp://www.ncsl.org/research/health/prescribing-policies-states-confront-opioid-overdose-epidemic.aspx

Nursing Community Coalition. (2017, November 9). Letter toHonorable Paul Tonko and the Honorable Ben Ray Lujan.Retrieved from https://docs.wixstatic.com/ugd/ 148923_8e6ad49f4fdf4ffdbeb0c0a74849792c.pdf

Rettig R.A., & Yarmolinsky A. (Eds.). (1995). Institute of Medicine (US)Committee on Federal Regulation of Methadone Treatment.Washington, DC: National Academies Press.

Shaw, A., Hayes, C., & Martin, B. (2017). Characteristics of InitialPrescription Episodes and Likelihood of Long-Term Opioid Use– United States, 2006-2015). Centers for Disease Control andPrevention Morbidity and Mortality Weekly Report, 66(10).Retrieved from https://www.cdc.gov/mmwr/volumes/66/wr/pdfs/mm6610.pdf

Substance Abuse and Mental Health Services Administration.(2016a). Bupronorphine. Retrieved from https://www.samhsa.gov/medication-assisted-treatment/ treatment/buprenorphine

Substance Abuse and Mental Health Services Administration.(2016b). SAMHSA Opioid Overdose Prevention Toolkit. Rockville,MD: Author.

U.S. Department of Justice and Drug Enforcement Agency. (2016).State Prescription Drug Monitoring Programs, June 2016.Retrieved from https://www.deadiversion.usdoj.gov/faq/rx_monitor.htm#4

Webb v. United States, 249 U.S. 96. (1919). Retrieved from https://supreme.justia.com/cases/federal/us/249/96/

Sarah Cluff, M.Ed, MS, RN, AG-CNS, is Adult GerontologicalClinical Nurse Specialist, Lifelong Medical Care, Berkeley, CA. Shemay be contacted at scluff@lifelongmedical.org

Controlled Trials and Observational Studies. Retrieved fromhttps://doi.org/10.1371/journal.pone.018001

Stamm, L.V. (2016). Syphilis: Re-emergence of an Old Foe. MicrobialCell, 3(9), 363–370. http://doi.org/10.15698/mic2016.09.523

United States Preventive Services Task Force (USPSTF). (2016).Syphilis Infection in Nonpregnant Adults and Adolescents:Screening. Retrieved from https://www.uspreventiveservices-taskforce.org/Page/Document/UpdateSummaryFinal/syphilis-infection-in-nonpregnant-adults-and-adolescents

Angela D. Alston, DNP, MPH, WHNP-BC, is Manager ofAdvanced Practice Providers, OhioHealth Physician Group,Columbus, OH. She may be contacted at angela.alston@ohio-health.com

Emerging Clinical Issuescontinued from page 9

12 ViewPoint MARCH/APRIL 2018

A Voice for Ambulatory CareNurses: Creation of anAmbulatory Care

Professional Practice CouncilThe Academic Health Center (AHC) at Indiana

University Health (IUH) Indianapolis supports multipleambulatory clinics across several campuses. As the shift ofhealthcare delivery changes from inpatient to outpatient,and the cost, technology, and patient focus is on wellnessversus the disease state, the ambulatory care services aremore complex than those offered in a community-basedpractice. Nationally, patients are discharged from the acutecare setting to the community faster, requiring vocalambulatory care nurses to design the care and servicestheir patients will receive.

This column describes the creation and implemen-tation of a cross-campus AmbulatoryProfessional Practice Council(APPC) shared governanceforum. Focused on the goal toadvance the art and science ofambulatory care nursing acrossthe patient care continuum, thecouncil’s purpose is to define andstrengthen the role of ambulatorycare nurses. The APPC is vested in sup-porting not only ambulatory care nursesbut all of the clinical support roles. TheCouncil’s mission is to provide exceptionalpatient care and satisfaction, at the lowestcost possible, across all the outpatient clinics.The council provides a mechanism to define, implement,and foster the highest standards of nursing practice, as wellas providing a forum for shared governance, collaboration,advocacy, accountability, and autonomy for ambulatorycare nursing practice. By doing this, the council ensuresthat all practices are ethical, theoretically sound and basedon the most current evidence.

BackgroundThe AHC of IUH consists of 2 adult facilities and 1 chil-

dren’s hospital. In 2012 ambulatory care leaders of both theadult and pediatric facilities expressed a strong desire to par-ticipate in the organization’s Magnet re-designation, whichwas traditionally an inpatient focused activity. As a directresult, an Ambulatory Care Magnet Committee was estab-lished. The director of pediatric ambulatory care services andan ambulatory care clinic manager were invited to join theorganization’s Magnet Steering Committee, which ensuredthat ambulatory care nursing was represented as the organ-ization prepared for the upcoming Magnet survey.

As the ambulatory care committee began to gatherexemplars for the Magnet components and sources of evi-dence, it became excitingly apparent how ambulatory carenursing contributed significantly to improving patient out-comes at every level and would be a great partner in there-designation process. The Magnet Recognition Programthrough the American Nurses Credentialing Center(ANCC) recognizes “quality patient care, nursing excel-lence, and innovations in professional practice” (ANCC,2014, p.1). A component of Magnet designated organiza-tions is the presence of a shared governance model thatbegins at the unit level, which includes all staff and is linkedto the organization as a whole. As first steps, in June 2012,the Riley Hospital ambulatory care nurses formed aPediatric Ambulatory Care Professional Practice Counciland one of the adult clinics formed their own professionalpractice council. These councils were the foundation forthe academic health center APPC.

Year 1: 2014/2015 The development and growth of shared

governance have been described withinhospital systems; however there is a signif-icant gap in the literature regardingshared governance within ambulatorycare systems (Meyers & Costanzo,2015). After our organization achievedMagnet re-designation, it becameapparent that ambulatory care nursesneeded to have a voice in their dailypractice and could make significant

contributions to positive patient out-comes. The most logical platform to accomplish this stepwas the development of an Ambulatory ProfessionalPractice Council.

The first step toward achieving our shared governancecouncil model was to develop a charter. The charter for theacademic health center APPC included mission and visionstatements that were consistent with the AmericanAcademy of Ambulatory Care Nursing (AAACN) NursingPractice standards and its vision. Furthermore, AAACN’sposition statement on the role of the registered nurseemphasized the importance of RNs in ambulatory care set-tings, and that RNs are best prepared to facilitate the func-tioning of inter-professional teams across the care continu-um, coordinate care with patients, and mitigate thecomplexities in care delivery (AAACN, 2017). The charteralso defined the criteria and expectations of all members.The founders of the council sought and received validationfrom the system chief nursing officer that the council’sdirection was aligned with the organization and nursingpractice. In so doing, the APPC ensured legitimacy andsupport for a major paradigm shift that would occur withinthe medical practices. Endorsement from key stakeholderswas received and the first meeting of the APPC was heldOctober 8, 2014.

Ambulatory care is logistically complex and more chal-lenging than acute care due primarily to less support pro-vided in managing care than in hospitals (Haas & Swan,

WWW.AAACN.ORG 13

2014). Four major goals were identified by the APPC in thefirst year:

Standardize job descriptions for all clinical roles in1.ambulatory care. Establish a standardized orientation plan for all clinical2.roles.Create a comprehensive plan to measure competen-3.cies for all roles.Design and implement an educational offering to4.engage and educate nurses about AAACN certification.

Council leadership decided early on that establishing aprocess to meet the first year goals was imperative for itssuccess. Sub-work groups were formed to address eachitem and reported their progress at the monthly councilmeetings. In April 2015, the council engaged a Lean SixSigma transformation officer to help focus and improve theefficiency of the council. This approach was extremelyhelpful and assisted members to understand the process ofthe project and aligned all involved toward the commongoals (Sprankle, Hamlin, Grayem & Musitano, 2015). TheAPPC became the link that connected ambulatory carenurses with each another and with the hospital system.

All 4 goals were successfully met in the first year. Thegoal for standardizing orientation evolved into a morefocused approach to develop a robust triage orientationprogram. The success of the first year of work was dissem-inated to AAACN colleagues via 3 posters at the 2017annual education conference.

Year 2: 2015/2016 Since the inception of the APPC, a major initiative

undertaken had been to identify a nursing-sensitive qualityindicator (NSI). The question posed was “How best canambulatory care nurses develop metrics to demonstratetheir positive impact on patient outcomes?”

The traditional NSIs in the inpatient world (central line-associated bloodstream infections, catheter-associated uri-nary tract infections and pressure ulcers) do not necessarilyapply in the outpatient setting. The APPC decided that aNSI focused on educating the patient on the importance ofutilizing a primary care physician (PCP) would be meaning-ful to both adult and pediatric specialty clinics. This patienteducation ideally would reduce the utilization of the emer-gency department and/or a specialist for routine medicalcare. For 2 months in 2015, the project was piloted in 3specialty clinics collecting data on 934 patients. The datashowed that patients did connect with a PCP after receiv-ing the materials and education provided by the staff in thespecialty clinic. Out of the 934 patients surveyed, 22patients established care with a new PCP and 101 patientsscheduled an appointment with their PCP after not beingseen within a 12-month timeframe.

The second phase of this project incorporated docu-mentation of PCP usage or education about the impor-tance of having a PCP into the electronic medical record(EMR). Standardizing the process within the EMR will allowelectronic auditing and consistency in collection of data.This NSI measure continued in 2017.

In 2016, the APPC began the work of standardizing anapproach for telephone triage orientation. A research studycomparing experienced and novice telehealth nurses onmeasures of competency and self-confidence wasapproved by the organization’s Institutional Review Board.The data collected indicated an improvement in scores fornew triage nurses who went through the orientation pro-gram. The experimental group surpassed the experiencedtriage nurses in competence as measured at the comple-tion of their orientation. Upon review of the competencyscores for both groups it was decided all ambulatory carenurses could benefit from the information presented in theclasses; this content is now delivered through self-paced,web-based training. After viewing the 6 modules, eachambulatory care nurse will complete the competencymeasures and the data will be analyzed to evaluate theeffectiveness of the online education. This will concludepart 2 of the study and hopefully results will be presentedto ambulatory care nurses in 2018.

Summary/Next StepsAs a result of the creation of the APPC, IUH ambulatory

care nurses have quantified and shared their impact onpatient outcomes through the NSI project and triage ori-entation study. Three posters were presented at the 2017AAACN annual conference and the Telephone Triage studydata was presented at the Canadian Association ofAmbulatory Care Nursing at their 2017 annual meeting.Through recognition by senior leadership, ambulatory carenurses now hold a seat on the system-level ProfessionalPractice Council. Ambulatory care provides a great oppor-tunity for transformational leadership in the era of healthcare reformation. In our organization, it began with thedevelopment of a Professional Practice Council that provid-ed ambulatory care nurses with a voice in their practice.Ambulatory care nursing is constantly changing and evolv-ing. As members of this professional group it is our respon-sibility to ensure our voice is heard.

ReferencesAmerican Academny of Ambulatory Care Nursing (AAACN). (2017).

Scope and standards of practice for professional ambulatory carenursing (9th ed.). C. Murray (Ed.). Pitman, NJ: Author.

American Nurses Credentialing Center (ANCC). (2014). Magnetrecognition program overview. Retrieved from http://www.nursecredentialing.org/Magnet/ProgramOverview

Haas, S.A., & Swan, B. (2014). Developing the value proposition forthe role of the registered nurse in care coordination and transi-tion management in ambulatory care settings. NursingEconomic$, 32(2), 70-79.

Meyers, M.M., & Costanzo, C. (2015). Shared governance in a clinicsystem. Nursing Administration Quarterly, 39(1), 51-57.

Sprankle, D., Hamlin, A., Grayem, K., & Musitano, A. (2015).Creating ambulatory shared governance through lean sixsigma strategies. ViewPoint, 37(2), 4-8.

Constance F. Buran, PhD, NE-BC, RN, is Director, PediatricAmbulatory Care, Riley Hospital for Children, Indiana University Health,Indianapolis, IN. She may be contacted at cburan@iuhealth.org

Amanda Adkins, MSN, RN, is Clinical Manager Urology Clinic,University Hospital, Indiana University Health, Indianapolis, IN.

14 ViewPoint MARCH/APRIL 2018

The Patient’s StoryHave you ever become frustrated when a person you

are talking to finished your sentences? Are you ever disap-pointed when you find yourself conversing with someonewho is distracted and not listening? Have you ever beenstopped mid-sentence as someone rushed through ques-tions or assumed they knew your responses? You cannottell your story because you are interrupted or disregarded.These communication glitches are annoying in conversa-tions with friends, family members, and co-workers, butwhen it occurs between a patient and nurse, there may bedeleterious outcomes.

This article is the fourth in a series that focuses onimplementing the concept of curiosity in nursing practice.Having a sense of inquiry can lead you to explore, investi-gate, and assess patients more comprehensively in both in-person and virtual encounters. This mindset is crucial forcare delivery, especially when the nurse and patient are notsharing the same space. When physical presence is miss-ing, the nurse and patient both have to rely on a deeperand more connected dialogue. This month, I will focus onhow the patient’s story can be captured through a sense ofinquiry during telehealth encounters.

The Story Within Telehealth Encounters In a busy clinic or call center there may be a sense of

urgency in managing telehealth encounters to quickly getthrough volumes of voicemail and electronic messageswhile juggling other tasks (e.g., refills, prior authorizations,nurse appointments). The demands that nurses face on adaily basis are substantial, but allowing the environmentalstressors to compromise telehealth encounters can lead toinefficient and inadequate care. The story needs to beheard for optimal patient-centered outcomes.

Curiosity Enhances Communication Nurses must possess exemplary communication skills

in both in-person and virtual dialogue with patients. By itsnature, telephone encounters createa challenge as you do not share the

same physical spaceas the patient. You

are not able to use your sense of sight and touch in theassessment process. Derkx et al. (2009) found that tele-phone triage nurses must focus on patient-centered com-munication and identified that patients are most satisfiedwhen the nurse is able to acknowledge their physical oremotional needs and provide necessary reassurance.Ernesater, Winblad, Engstrom, and Holstrom (2012)reviewed malpractice claims following telephone callsmanaged by telenurses and found that communicationfailure was the most common cause of errors.

It is crucial to ask open-ended questions and listendeeply to understand the patient’s situation. Think aboutwhen you have observed an exceptional interview. Theinterviewer is not distracted, rushed, or presumptuous.Capturing the patient’s story will require effective dialogue;the nurse must use open-ended questions and listen withfocus.

Listening is important in communication. It isresponsible nursing practice and requires concentra-tion of attention and mobilization of all the senses forthe perception of verbal and non-verbal messagesemitted by each patient. By listening, nurses assessthe situation and the problems of the patient; theyenhance his/her self-esteem and integrate both thenursing diagnosis and the process of care at all levels(Kourkouta & Papathanasiou, 2014. p. 66).

As you guide the conversation with your questions, itis important to allow the patient time to describe whatthey are experiencing. As they speak, engage in active lis-tening by not only hearing the words but also empathizingwith situation and reflecting on the information. Sayingthings such as “I understand,” “go on,” “this must be dif-ficult,” and “what I hear you saying is…” indicates to thecaller that you are listening without distraction. You arebuilding rapport and trust as the story is unfolding.

The Patient’s Record Contains Part Of the Story

Reviewing the patient’s record reveals more of thestory. This does not mean that you have to do a thoroughchart review with every telephone encounter but it isimportant to consider relevant information such as thepatient’s problem list, medication list, and allergies. Apatient recently shared a perspective: “It would be nicewhen a nurse is on the phone with me that she knew a lit-tle about me. Many times I want to ask them if they evenlooked at my record…it’s all there. We could save so muchtime.” As described, reviewing the patient’s record canlead to a more fluent and effective encounter. Hubers,Keizer, Giesen, Grol, and Wensing (2012) explored theimpact of telephone triage nurse consultation and foundthat not only are quality communication skills necessarybut there is value in being aware of the patient’s historyand completing adequate documentation in order to makeappropriate decisions.

WWW.AAACN.ORG 15

Health Portals Abbreviate the Story I would be remiss if I did not address health portal

communication. Patient portals were introduced andadopted by a few large healthcare organizations in the late1990s but development was accelerated by meaningfuluse (MU) criteria of the Centers for Medicare & MedicaidServices Electronic Health Record Incentive Program(Irizarry, DeVito Dabbs, & Curran, 2015). Patient portalsare being used with increased frequency to book appoint-ments, record symptoms, and communicate withproviders. Rybolt (2017) reports that 45% of patients atsmall practices and 30% of patients at national and region-al health systems use portals, but it is projected the adop-tion and usage will increase.

Health portals can be effective for some types of com-munication between patient and team, but there are limi-tations. When a patient attempts to relay symptomsthough a portal, the nurse cannot see, touch, or even hearthe patient. The patient’s voice is absent and the ability toobtain a comprehensive assessment is substantially com-promised. Not only is accuracy impaired, efficiency is lostas the nurse and patient need multiple exchanges and thepatient’s story is nearly impossible to capture.

Although portals are appropriate for accessing visitsummaries, completing surveys, or requesting prescriptionrenewals, symptom management should ideally be com-pleted by a voice-to-voice connect with the nurse andpatient. When patients submit questions about symptoms,it is appropriate to advise the patient to call the clinic. If themessage identifies symptoms that the nurse assesses to bepotentially urgent, the nurse should call the patient. It isonly through verbal dialogue that the nurse can capture amore complete patient story and provide optimal care.

ReferencesDerkx, H.P., Rethans, J.E., Maiburg, B.H., Wuinkens, R.A., Muijtjens,

A.M., Van Rooij, H.G., & Knottnerus, J.A. (2009). Quality ofcommunication during telephone triage at Dutch out-of-hourscentres. Patient Education and Counseling,74, 174-178.

Ernester, A., Winblad, U., Engstrom, M., & Holstrom, I.K. (2012).Malpractice claims regarding calls to Swedish telephone advicenursing: what went wrong and why? Journal of Telemedicineand Telecare,18, 379-383. doi:10.1258/jtt.2012.120416

Hubers, L., Keizer, E., Giesen, P., Grol, R., & Wensing, M. (2012).Nurse telephone triage: good quality associated with appropri-ate decisions. Family Practice, 29, 547-552. doi:10.1093/fam-pra/cms005

Irizarry, T., DeVito Dabbs, A., & Curran, C. R. (2015). Patient portalsand patient engagement: A state of the science review. Journalof Medical Internet Research, 17(6), e148. Doi:10.2196/jmir.4255

Kourkouta, L. & Papathanasiou, I. (2014). Communication in nurs-ing practice. Mater Sociome, 26(1). 65-67. doi:10.5455/msm.2014.26.65-67

Rybolt, O. (2017). 4 keys to patient portal engagement.Athenainsight. Retrieved from https://www.athenahealth.com/insight/4-keys-patient-portal-engagement

Kathryn Koehne, DNP, RN-BC, C-TNP, is Clinical Manager -Ambulatory Care, Gundersen Health System; Adjunct Facultyat Viterbo University; and Professional Educator, Telehealth TriageConsulting, Inc. She may be contacted at krkoehne@gundersenhealth.org

Christine Ruygrok Appointed toAAACN Board of Directors

Christine Ruygrok, MBA RN-BC, hasbeen appointed as a Director on theBoard of Directors effective at the closeof the AAACN 2018 Annual Conference.Christine will complete the remainingone-year term of Kristene Grayem, MSN,CNS, PPCNP-BC, RN-BC, who will

vacate her Director position to serve as President-Elect ofAAACN. Christine has been an active member of AAACNsince joining in 2012. Congratulations, Christine!

Care Coordination Transition Management ToolkitThe passage of the Affordable Care Act has impacted

the delivery of health care in our healthcare organizations.Healthcare systems are accountable for providing betterpatient care, improving the health of populations, andreducing costs. One way to achieve these aims is throughimproved care coordination and management of transi-tions.

The new Care Coordination and TransitionManagement (CCTM) Toolkit was developed by theCCTM Toolkit Task Force as an interactive online tool thatprovides evidence-based resources for implementingCCTM structure, process, and outcome tools into practiceand supports nurses in their roles of care coordination andtransition management.

The CCTM Toolkit offers useful tools that support the9 core dimensions of CCTM, as well as resources for pedi-atrics. The toolkit will feature organizational exemplars ofCCTM, current CCTM resource information, and a largevolume of evidence-based tools that support CCTM inhealth care. AAACN members will soon be able to accessthe interactive CCTM Toolkit on the AAACN website,which will allow members to contribute and share currentinformation and resources to support the role of CCTMnurses and core curriculum.

Stay tuned for this exciting new resource to debut in2018! Members of the CCTM Toolkit Task Force will sharemore information when they present the session, “Usinga Collaborative Approach to Build the Care Coordinationand Transition Management (CCTM) Toolkit,” at theAAACN Annual Conference in May.

AAACN is a welcoming, unifying community for registered nurses in all ambulatory care settings. Our mission is to advance the art and science of ambulatory care nursing.

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Volume 40, Number 2

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AAACN Board of Directors

PresidentLiz Greenberg, PhD, RN-BC, C-TNP, CNE

President-ElectKathy Mertens, DNP, MPH, RN

Immediate Past PresidentDebra L. Cox, MS, RN, CENP

Director/SecretaryCAPT (Ret.) Wanda C. Richards, PhD, MPA,MSM, BSN

Director/TreasurerKristene Grayem, MSN, CNS, PPCNP-BC, RN-BC

DirectorsRocquel Crawley, DHA, MBA, BSN, RNC-OB,NEA-BCAnne T. Jessie, DNP, RNKathleen Martinez, MSN, RN, CPN

Chief Executive OfficerCynthia Nowicki Hnatiuk, EdD, RN, CAE, FAAN

Director, Association ServicesLinda Alexander

AAACN ViewPointwww.aaacn.org

EditorKitty M. Shulman, MSN, RN-BC

Editorial BoardSarah Muegge, MSN, RNJoan M. Paté, MS, BSN, RN-BCJanis S. Tuxbury, DNP, RNTracy Weistreich, PhD, RN, NEA-BC, VHA-CM

Manuscript Review PanelRamona Anest, MSN, RNC-TNP, CNEAdrienne Banavage, MSN, OCN, RN-BCDeanna Blanchard, MSN, RN-BCAmi Giardina, DNP, MHA, RNLiz Greenberg, PhD, RN-BC, C-TNP, CNEAnne McLeod, DNPc, RNJennifer Mills, RNC, CNS-BCTerrie Rill, MBA-HCM, BSN, RN, CCMCPamela Ruzic, MSN, RN-BCAssanatu (Sana) I. Savage, PhD, DNP, FNP-BCMary H. Vinson, DNP, RN-BCStephanie G. Witwer, PhD, RN, NEA-BC

Managing EditorSarah Black, MS

Editorial CoordinatorJackie Massaro

Layout DesignerBob Taylor

Education DirectorRosemarie Marmion, MSN, RN-BC, NE-BC

Marketing DirectorTom Greene

Congratulations to New AAACN CEO Linda Alexander

Linda Alexander has been appointed as our new AAACN ChiefExecutive Officer. Some of you may know Linda from her current role asAAACN Director of Association Services. Linda brings over a decade ofassociation management experience to her new role. She began employ-ment at our management company, Anthony J. Jannetti (AJJ), as thePublic Relations and Marketing Manager where she launched her workwith AAACN. Linda also served as the Managing Editor for publicationsand online marketing, and Conference Manager. Prior to her AAACN

director role, Linda served as the Business Development Manager for AJJ.

“I am so excited and honored to be named the next AAACN CEO,” said Linda. “I lookforward to continuing to work closely with our Board of Directors, volunteer leaders, andstaff to advance the mission of this incredible professional nursing association.”

Her official appointment will begin in May at the 2018 AAACN annual conference. Youmay contact Linda at linda@aaacn.org.

AAACN Conference Connection

We are looking forward to seeing many members at the Annual Conference in May.Check your email for:

Important conference reminders•Downloading session handouts•Accessing the conference app •Evaluating conference sessions to earn your contact hours•

conference.aaacn.org

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