Perspectives in Ambulatory Care Susan M. Hossli Rachel Start Marcia P. Murphy Implementation and Evaluation of an Ambulatory Care Nurse Clinical Advancement System EXECUTIVE SUMMARY The United States spends more than other highincome countries on health care, while continuing to lag behind in quality, access, life expectancy, and care coordination. Patient populations and where they receive care is changing drastically, with volumes shifting from the inpatient, episode-centered model to an outpatient, health promotion centered model. Ambulatory care nurses are uniquely positioned within the healthcare continuum to lead the transformation of care for diverse patient populations. One strategy that enables the ambulatory care nurse to practice all dimensions of his or her specialty role is the development of a clinical advancement system (CAS). CAS, or clinical ladders, are one strategy that can assist nurses in acquiring skills necessary to support excellent practice as well as improve quality patient care outcomes. THE UNITED STATES SPENDS more than other highincome countries on health care, while continuing to lag behind in quality, access, life expectancy, and care coordination (Schneider, Sarnak, Squires, Shah, & Doty, 2017). A landmark report from the Institute of Medicine (IOM, 2010) discussed the imperative for nurses in all settings to Susan M. Hossli engage as full partners in the redesign of a healthcare system that optimizes care and outcomes. The IOM suggested several strategies that would empower nursing to fulfill this role including practicing to the full extent of a nurse s education and pursuit of the highest levels of education. SUSAN M. HOSSLI, MSN, RN, NEA-BC, is Director of Ambulatory Nursing Practice, Rush University Medical Center, Chicago, IL. RACHEL START, MSN, RN, NE-BC, is Director, Ambulatory Nursing and Nursing Practice, Rush Oak Park Hospital, Oak Park, IL. MARCIA P. MURPHY, DNP, ANP, FAHA, FPCNA, is Program Director of Adult-Gerontology Primary Care NP and CNS Programs, Associate Professor/Adult Nurse Practitioner, Department of Adult and Gerontological Nursing, Rush University College of Nursing, Chicago, IL. Registered nurses (RNs) in ambulatory care have not traditionally benefitted from an emphasis on autonomy, leadership, and practice management; remaining unprepared in many settings to embrace the challenge to create solutions for the burgeoning volume of patients coming their way (Start, Matlock, & Mastal, 2016). Patient populations and where they receive care are changing drastically, with volumes shifting from the inpatient, episode-centered model to an outpatient, health promotion centered model (American Academy of Ambulatory Care Nursing [AAACN], 2017; American Hospital Association, 2016; IOM, 2010). Ambulatory care nurses are uniquely positioned within the healthcare continuum to lead the transformation of care for diverse patient populations. Nurses are the ideal team members to help expand primary care capacity and improve care coordination in complex patient populations; however, they have been underutilized to date in these settings (AAACN, 2017; Bodenheimer & Mason, 2017; IOM, 2010). Ambulatory care nurses work within the context of a specialty, with standards and scope that guide their practice, a certification unique to their practice environment, and an association to guide practice improvement (AAACN, 2017). Clinical advancement systems (CAS), or clinical ladders, are strategies that can assist nurses in acquiring skills necessary to support excellent practice as well as improve quality patient care outcomes (Fardellone & Click, 2014). The American Nurse s Credentialing Center s (ANCC) Magnet Recognition Program is a catalyst for positive change in nursing practice. CAS are also strategies that many organizations use to meet ANCC Magnet Program criteria. Ambulatory nurses are now part of the Magnet process within the organization (ANCC, 2013, 2017). Background Nursing CAS have been well established in the inpatient setting as a means of advancing nursing practice, improving retention, improving engagement, and promoting better patient outcomes (Krugman, Smith, & Goode, 2000; Murphy, Hinch, NOTE: This column is written by members of the American Academy of Ambulatory Care Nursing (AAACN) and edited by Kitty Shulman, MSN, RN-BC. For more information about the organization, contact: AAACN, East Holly Avenue/Box 56, Pitman, NJ 08071-0056; (856) 256-2300; (800) AMB-NURS; FAX (856) 589-7463; Email: aaacn@ajj.com; Website: http://aaacn.org 149
Llewellyn, Dillon, & Carlson, 2011; Nelson & Cook, 2008; Robinson, Eck, Keck, & Wells, 2003). Recently, CAS have evolved in ambulatory care settings with some promising results. A CAS implemented at Kaiser Permanente of Colorado for ambulatory care nurses provided financial incentives to RNs who demonstrated a commitment to leadership activities, continuing education, and program development on local and regional levels. This program resulted in increased RN leadership and quality improvement activities for those participating in the CAS with no significant change in job satisfaction compared with those RNs who chose not to participate (Nelson & Cooke, 2008). Challenges have been identified in implementing CAS in the ambulatory care setting. Streeter (2006) reported that interest and participation in the CAS in a multi-specialty clinic setting was low. The lack of opportunity for professional development in the ambulatory care arena was identified as a challenge. Furthermore, the organizational structure within the ambulatory care setting often includes department managers who are not RNs. This poses challenges regarding knowledge of nursing practice and its advancement. Woolsey and Bracy (2012) described a comprehensive process to develop a CAS for ambulatory care RNs in a large northern California healthcare system. However, 4 years later, the CAS program was still not implemented because of a lack of engagement of a key stakeholder group, the nursing staff, early in the development process. One health system s successful implementation of an ambulatory care clinical advancement system and the resultant outcomes are described in this column. Setting The healthcare system developing the ambulatory care CAS has a long tradition of nursing innovation, leadership, and professional practice accountability. Innovations, including a shared governance model and a clinical ladder for acute care nurses, were established in the 1970s and early 1980s. The acute care CAS was updated in 2008 to align performance expectations with the organization s professional practice model, thereby ensuring the underlying principles are evident in everyday practice. The outcomes of the CAS update were positive including an increase in the percentage of nurses with baccalaureate degrees and certifications (Murphy et al., 2011). Professional practice models (PPMs) provide a conceptual framework for establishing professional nursing practice. ANCC s Magnet Recognition Program describes a PPM as a schematic description of a system, theory, or phenomenon that depicts how nurses practice, collaborate, communicate, and develop to provide the highest quality care for those served by the organization. Integration of the health system s PPM into the ambulatory CAS presented an opportunity to further align all nursing services under the same practice identity and dimensions. The foundation of this system s PPM is relationships and caring, propelled by critical thinking, evidence-based practice, and technical expertise to create a synergy that promotes the nurse as a leader in his or her environment. Each domain is reflected in the many structures and processes that allow RNs to evaluate and advance their practice. The previously identified PPM s five domains are integrated within the CAS, nursing job descriptions, performance evaluation, peer evaluation, interview and exit interview processes, awards, leadership development programs, new graduate nurse orientation programs, and many other important practice-related structures. Process A steering committee was established to redesign the role of professional nurses in the ambulatory care setting. Because this initiative represented a transformational change, key leaders across the system were included in the development and approval process. The steering committee included Magnet program directors, vice presidents of nursing, and shared governance presidents at both organizations within the health system; the director of professional nursing practice at one of the organizations; and affiliated college of nursing faculty that had experience in developing CAS in the inpatient setting. The leadership vision of this group was to utilize RNs to the fullest potential of their scope in order to have optimal patient care outcomes and enhanced interprofessional collaboration. The explicit purpose of the committee was to develop, implement, and evaluate a CAS. A comprehensive plan was established to develop the CAS which included review of the literature, conducting focus groups, developing the first draft of job descriptions, and review and validation by an expert panel. The process created a vision for ambulatory care nursing in the system. Focus Groups Focus groups were used to determine the perspectives of nursing staff and leadership regarding current nursing practice in the ambulatory care setting. The health system s institutional review board approval was secured for this process. The focus groups were held in a convenient, comfortable environment and led by an experienced focus group facilitator which was important to promote open disclosure among the participants (Krueger & Casey 2015). A second facilitator took detailed minutes of the discussion. A total of 16 professional nurses and nurse leaders representing the various ambulatory care specialties participated in the focus groups. Twelve openended questions were developed based on the health system s PPM. The questions were reviewed by a qualitative expert for face and content validity. The 150
data generated by the focus groups were analyzed using methods proposed by Krueger and Casey (2015). The data were coded and synthesized to identify themes. The themes represented role responsibilities of ambulatory care nurses across several specialty areas. CAS Draft Development Benner s (1984) model, From Novice to Expert, was used as the theoretical framework to define advancement of competencies. This model has been used often in the development of CAS (Krugman et al., 2000; Murphy et al., 2011; Robinson et al., 2003). A profile description of each level was developed based on Benner s model which served to guide the development of the competencies within each level. The specific competencies within each level were organized based on the domains of the PPM. The goal was to develop core competencies that would be applicable to nursing practice across all the ambulatory care specialty practices. The themes identified in the focus groups served as a foundation for developing the competencies. It was important to incorporate the leadership vision for ambulatory care nursing practice as well. In addition, key documents were reviewed and integrated including: The Scope and Standards of Practice for Professional Ambulatory Care Nursing (AAACN, 2010), The Role of the Registered Nurse in Ambulatory Care Position Statement (AAACN, 2011), Institute of Medicine Future of Nursing: Leading Change, Advancing Health (IOM, 2010), and National Quality Forum endorsed care coordination measures (NQF, 2012). This work culminated in the first draft of the CAS which included three job descriptions that delineated advancing competencies within the ladder. Expert Panel Review An expert panel comprising nursing leadership across the ambulatory and acute care settings was charged with reviewing and approving the draft job descriptions. This expert panel was used to establish content validity. Specific questions considered by the panel included: (a) Does the competency reflect current practice or the nursing vision for practice? (b) Do the job descriptions clearly differentiate advancing practice at each level? (c) Is each competency clearly worded? and (d) Is the competency feasible to achieve? This work was conducted over several meetings. There was considerable discussion regarding inclusion of a novice level in ambulatory care. The panel ultimately decided a novice nurse would not have the knowledge, skills, and experience to practice ambulatory care independently within this system. Therefore, the panel recommended the three job descriptions be collapsed into two: Ambulatory RN2 and Ambulatory RN3. Explicit qualifications were developed for each level. For example, a baccalaureate degree and national certification are required for consideration of promotion to the Ambulatory RN3 level. See Table 1 for an example of one domain in the CAS, leadership, and how it incentivizes increased leadership from Ambulatory RN2 to Ambulatory RN3, while also underscoring the role of leadership for all nurses. Implementation A comprehensive plan for implementation was developed which included human resource activities, development of CAS policies and procedures, nurse education, and a marketing strategy. The shared governance organization s influence and structure were leveraged to support this process. The CAS was implemented throughout all ambulatory care areas in the health system and promoted leadership at every level of nursing. The organization s human resources department was a significant partner in the implementation of CAS. In collaboration with ambulatory care nursing leadership, human resources incorporated the job descriptions into the system. Advancement to Ambulatory RN3 included a salary differential and an increase in job grade. The pay increase was independent of annual merit increases. A strategy was developed to transition all ambulatory care nurses to the CAS as Ambulatory RN2s. The result was that the number of ambulatory care nurse job titles was reduced from six to two, standardizing the job requirements across the organization. In tandem with the work on job descriptions, two CAS policies and procedures were developed: one on initial advancement to Ambulatory RN3 and the second policy on the Ambulatory RN3 renewal process. The CAS policy to advance to Ambulatory RN3 includes submission of a letter of intent, résumé, most recent performance evaluation, and portfolio. The CAS process begins when a RN requests consideration for advancement from his or her manager. If the manager approves the submission, the director of ambulatory nursing practice (director) reviews the submission and has the responsibility to approve or deny. This step in the process provides oversight and ensures consistency across all specialty areas within the system. If the director approves the submission, it is reviewed by the professional nurse advancement committee (committee) which comprises eight ambulatory care nurses and nurse managers. The committee meets twice a year and has final approval of all applications for advancement. All RNs are interviewed by the committee. Approval for advancement requires 75% majority vote of the committee with a quorum of six committee members. If the director or committee denies the submission, a meeting is held with the RN and RN manager to discuss reasons for denial of advancement and areas for improvement. A mutually agreed upon action plan with timeline is 151
Table 1. Comparison of Ambulatory RN2 and Ambulatory RN3 Job Description Competency RN2 Ambulatory RN3 Ambulatory General Summary The Ambulatory RN2 is a competent RN who exemplifies the organization s mission, vision, and values and acts in accordance with the organization s policies and procedures. The Ambulatory RN2 identifies patterns of patient responses and can use past experiences to implement solutions for current situations. The Ambulatory RN2 is a competent nurse who has mastered technical skills and utilizes evidencebased interventions. Ambulatory RN2 continues to collaborate with other members of the healthcare team when the need for assistance is identified. General Summary The Ambulatory RN3 is a proficient RN who exemplifies the organization s mission, vision, and values and acts in accordance with the organization s policies and procedures. The Ambulatory RN3 is a proficient nurse possessing an in-depth knowledge of patient management; can accommodate unplanned events and can respond with efficiency, flexibility, and confidence. The Ambulatory RN3 immediately sees the whole situation while being able to discriminate that which is most relevant; has developed advanced communication and collaboration skills along with system savvy. The Ambulatory RN3 assumes a leadership role in the clinical practice area, using clinical experience to serve as a role model and coach. Leadership Demonstrates accountability for own professional practice, including progress toward achievement of annual goals. Leadership Demonstrates accountability for own professional practice, including progress toward achievement of annual goals. Considers factors related to resource utilization when delivering care to patients and families. Participates in interprofessional shared decision making to improve ambulatory care nursing practice, organizational performance, and outcomes. Supports clinic goals and change initiatives and participates in nursing shared governance. Develops and leads implementation of clinic goals, change initiatives, and nursing shared governance activities. Collaborates with other clinic personnel to ensure task completion to consistently optimize patient outcomes. Collaborates and evaluates the practice of professional and unlicensed staff consistently to optimize patient outcomes. Provides education to staff and/or students in the clinic. Identifies and develops educational opportunities for staff and/or students in the clinic. Serves as a role model whose beliefs, attitudes, and actions support clinic and institution leadership and goals. Manages resources effectively and contributes to realizing the fiscal goals of the practice; or Considers fiscal and budgetary implications in decision making regarding practice and system modifications. Leads initiatives to improve nursing practice, organizational performance, and patient outcomes. 152
Figure 1. Ambulatory Nurse Engagement Data 2013-2017 50% 45% 40% 35% 30% 25% 35% 28% 44% 46% 42% 25% 35%33% 41% 20% 15% 10% 5% 7% 7% 5% 11% 14% 15% 13% 0% Disengaged Ambivalent Content Engaged 2013 2014 2015 2016 created. Ambulatory RN3s are required to submit updated materials to the committee on a biennial basis to determine whether Ambulatory RN3 competencies have been maintained. RNs transferring from an inpatient area to ambulatory care as an acute care RN3 have a year before submitting materials to support their functioning at the Ambulatory RN3 level. Mandatory educational sessions were conducted and continuing nurse education credits were granted. The purpose of these sessions was to introduce the CAS, provide context for its relevance, and engage nurses in an innovative vision for practice in the ambulatory care setting. Chief nursing officers and shared governance leaders participated in these sessions to highlight the significance of this initiative as well as the ambulatory care nurse s connection to the whole system. After a widespread education process, meetings with small groups of nurses across the system were held. The purpose of these meetings was to solicit current examples of how nurses demonstrated the competencies within the job descriptions, and engage nurses, the key stakeholder group, in this major change initiative. These examples were taken and collated into marketing documents that helped other nurses understand the competency statements through tangible real-life practice examples. A comprehensive marketing strategy was employed to educate all ambulatory care RNs on the new CAS. Education was placed into branded, professionally designed booklets for future use. Use of the organization s intranet was employed to place resources and remind RNs of structures and processes that would promote their advancement of practice. Outcomes In July 2015, 160 ambulatory care nurses were successfully integrated into the CAS. The organization has seen positive outcomes through implementation of the CAS including ambulatory care nurse engagement, percentage of nationally certified ambulatory care nurses, and number of ambulatory care nurses participating in shared governance. Since implementation of the CAS, eight ambulatory care nurses advanced to Ambulatory RN3 and one acute care RN3 successfully transferred to an Ambulatory RN3 role. In 2013, using The Advisory Board Company (2007) employee engagement survey, an initial nurse engagement survey was conducted prior to the initiation of activities related to CAS. At that time 25% of ambulatory care nurses were described as engaged, which was under the survey tool s 25th percentile national benchmark, and 35% were considered disengaged. In 2017, 41% of nurses were engaged, which was at the survey tool s median national benchmark (see Figure 1). To advance to an Ambulatory RN3, nurses are required to have national nursing certification. A certification acknowledgment policy was implemented at the same time as the CAS. Newly nationally certified nurses receive a $400 bonus and the organization pays for the cost of any certification review courses or books and the certification test through education benefits. In 153
2015, 51% of ambulatory care nurses were certified and this percentage increased to 67% by 2017. While the CAS was being implemented, shared governance in ambulatory care was also developed. The organization has a long history of shared governance in the inpatient setting but this important structure was not inclusive of the ambulatory care setting. In 2013, the shared governance structure was implemented in ambulatory care nursing with the majority of participants being ambulatory care nurse leaders. At the end of 2017, the ambulatory care shared governance structure included five standing committees with membership at 95% ambulatory staff nurses and these committees were chaired by ambulatory care staff nurses. Discussion Knoche and Meucci (2015) identified key strategies needed for the successful implementation of a CAS. These strategies include a supportive organizational structure, professional development, and key stakeholder engagement. However, many challenges have been identified in the development and implementation of CAS in ambulatory care settings (Nelson & Cooke, 2008; Streeter, 2006; Woolsey & Bracy, 2012). This organization overcame the challenges in implementing the ambulatory care CAS. The long history of a strong nursing shared governance model and inpatient CAS provided a supportive framework. In addition to strengthening the shared governance structure in ambulatory care nursing, implementation of the ambulatory care CAS allowed for alignment with the rest of the organization s structure. Strong support and engagement at all levels of nursing was integral to the success of the CAS implementation. Nurses could opt-out of the ambulatory care CAS models described in the literature (Nelson & Cooke, 2008; Streeter, 2006; Woolsey & Bracy, 2012). In contrast, this organization placed all ambulatory RNs into the Ambulatory RN2 role, with the option of advancing to the Ambulatory RN3 if they meet eligibility criteria. Prior to implementation of the CAS, ambulatory nurses had no opportunity for advancement. The CAS provides a framework to encourage nurses to assume leadership responsibilities and participate in their professional development. Ambulatory RN3s developed cancer support programs, participated in the development of international evidence-based practice guidelines, and completed quality improvement projects that significantly improved patient outcomes. Conclusion Many organizations currently under-utilize nurses in the ambulatory care setting. Several factors influence this such as a lack of understanding of the dimensions of ambulatory care nursing practice, existing organizational culture, structure, and resources (AAACN, 2010, 2011, 2017). 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