Nursing Week 3 _ Assignment_ IMPACT OF NURSES ON HEALTH CARE QUALITY

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Perspectives in Ambulatory Care

Ambulatory care nursing is a specialty that is emerging as uniquely capable of meeting various challenges across the

healthcare continuum (American Academy of Ambulatory Care Nursing [AAACN], 2017). As the current healthcare delivery system navigates a pandemic, the realities of the sobering poor outcomes, lack of access, and equitable care that were present before 2020 persist (Emanuel et al., 2020; Radley et al., 2020). The need for healthcare transformation and nursing’s role as leader within that mandate is related to the growing volume of complex, chronically ill, vulnerable populations, in addition to inefficiencies associated with coverage, transitions of care, and services offered throughout the continuum (Haas et al., 2019; Schneider et al., 2017). This current reality, along with the pandemic, underscores the need for nursing, in every setting and role, to take a leadership stance, growing its scientific knowledge base to meet the dynamic needs of the populations it serves (AAACN, 2017; Institute of Medicine [IOM], 2010). Embracing and advancing the ambulatory care nurse’s role as this transformation occurs may improve the nursing profession’s ability to meet the social contract it shares with the public to improve and advance health (American Nurses Association [ANA], 2010; Start et al., 2018).

Shifting Landscape: Ambulatory Nursing and Value-Based Health Care

Comorbidities, psychosocial needs, frailty, and social determinant factors, among other complexities of patient care, create challenges for seamless care coordination and health promotion (ANA, 2013; Freeman, 2006). Additionally, with health care’s focus shifting from a fee-for-service, episodic, acute care approach to that of value, health, and efficiency across the patient’s lifespan and continuum, volumes are also shifting from inpatient to outpatient (American Hospital Association, 2018; Berwick et al., 2008; Schneider et al., 2017).

Leveraging the role of the ambulatory care nurse, who often sees patients for many years, serving in their communities, may increase the value of health care for patients across the continuum (Start et al., 2018; Start et al., 2020). In this setting, nursing practice has not traditionally had support for structures or processes that promote practice commensurate with their education and training (Start et al., 2016). It is vital nursing embraces this value-based perspective, creating interventions and deepening discipline-specific science that is responsive to the progressive focus on health rather than disease. RNs must be prepared to articulate their contribution to value-based care for patients and populations alike (Brown et al., 2020; Haas et al., 2019; Start et al., 2020).

Advancing the Science of Nursing: Ambulatory Care Nursing and Magnet® Designation Rachel Start Rebecca Graystone

As health care shifts from an acute, disease, and episodic-based model to one of health, community intervention, and continuum- focused interventions, the ambulatory care nurse is essential in this transformation and its success. Leveraging the ANCC Magnet® Model as a blueprint to improved patient outcomes and care of the nursing workforce can ensure that transformation is achieved.

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Nursing Community Response: Supportive Strategies at a High Level

As a profession, nursing is given the power to self-regulate, grow its own body of knowledge, and govern its practice and practitioners. In response to this authority, the profession is accountable for returning to society the promotion of health in its many populations (ANA, 2010; Donabedian, 1976). Self-regulation and professional governance are realized through nurses who practice to the full extent of their license and education, fully supported and competent (Clavelle et al., 2016) to conduct “constant surveillance so that departure from standards can be detected early and corrected” (Donabedian, 1978, p. 836). The IOM (2010) Future of Nursing report noted the nursing profession, due to its “numbers and adaptive capacity was perfectly poised to bridge the gap between coverage and access…to enable the full economic value of its contributions to be realized” (p. 1). Further, AAACN, the specialty organization for ambulatory care nurses, in their nursing position paper on the “Role of the Registered Nurse in Ambulatory Care” stated,

Creating a future that maximizes the role of RNs in an evolving healthcare environment will require sustained momentum in nursing practice, education, research, and leadership…to build the science of ambulatory care nursing, clinical nurse researchers must be engaged in the development of new knowledge and innovation to build the evidence base needed to support ambulatory care practice. (2017, p. 6) From 2013 to 2019, the AAACN nurse-

sensitive indicator taskforce identified, developed, proposed, and pilot tested 15 measures to reflect the quality of care delivered by ambulatory care nurses (AAACN, 2017; Haas et al., 2019; Start et al., 2016; Start et al., 2018). A benchmarking structure, where clinical sites could compare across specialty, volume size, organizational service line, and system, was also developed (Start et al., 2018). These measures and adjoining benchmarking database are now a part of the Press Ganey portfolio, which also offers inpatient

nurse-sensitive measures through the National Database of Nursing Quality Indicators.

ANCC Magnet Program Description of Program and Ambulatory Requirements

The American Nurses Credentialing Center’s (ANCC) Magnet Recognition Program® has been strongly linked to improvement of workforce and patient outcomes through the integration of the Magnet model as a vehicle for nursing excellence (Barnes et al., 2016; Friese et al., 2015; Lal, 2020; Stimpfel et al. 2016). The Magnet Recognition Program was started due to a study conducted by an American Academy of Nursing taskforce on Nursing Practice in Hospitals that identified work environments that attracted and retained well- qualified nurses while also obtaining excellent outcomes (ANCC, 2021). Forty-one organizations that qualified for the original study were able to attract and retain well-qualified nurses amid a national nursing shortage. Those organizations had common themes of structure, process, or outcome based on the current empirical Magnet model clustered in five domains: Transformational Leadership; Structural Empowerment; Exemplary Professional Practice; New Knowledge, Innovations, & Improvements; and Empirical Outcomes. These domains are surrounded by the dynamic and contemporary issues encompassing nursing and global health care (ANCC, 2017) (see Figure 1). As of December 2020, 548 (including 12 international organizations) or about 8.5% of registered U.S. hospitals achieved Magnet recognition and, as such, are known for excellence in outcomes within the five components (ANCC, 2020).

Magnet-designated organizations demonstrate strong nursing professional governance, collaboration, advocacy, research and innovations, and patient and staff outcomes. Combined, these factors provide evidence of enculturated Magnet principles across all settings where all levels of RNs practice. In 2019, the ANCC Commission on Magnet enacted a new set of standards, which more broadly emphasized ambulatory care nursing’s evolution into the recognition process (ANCC, 2017). Ambulatory care nurses must continue to show evidence of the same structures

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as other settings within the applicant organization, practice oversight by the chief nursing officer (CNO), and provide proof of outcomes related to nursing care delivery, workforce, and patient care. As ambulatory care nursing practice continues to shape and define care delivery, the Magnet Recognition Program monitors growing evidence and confers with experts in this specialty setting, including AAACN. Further, the Commission on Magnet includes a member with ambulatory care nursing care expertise.

AAACN, the specialty body of nurses who work to advance nursing care in the ambulatory care setting, has supported the maximization of the role of RNs in the evolving healthcare environment via numerous strategies and tactics. Authoritative position statements, rigorous work to develop nurse-sensitive indicators, white papers on telehealth and nurse transition to practice, and toolkits that support the growing role of the nurse executive in ambulatory care are among the supportive tools available. Additionally, standards and scope for the role of RNs as well as that of the nurse in care coordination and transition management, along with adjoining specialty certifications, are available to support excellent practice in the ambulatory care RN. ANCC required elements

crosswalked to the resources available from AAACN are listed in Table 1.

As organizations have sought to meet ANCC standards for Magnet recognition, several strategies have emerged as key to integrating the Magnet model into nursing practice and the organization, in all settings, inclusive of ambulatory care. Contacting the Magnet Program Office (MPO) is the first strategic step to understand the Magnet application and scope and breadth of the appraisal process, including requirements to maintain the credential. Magnet standards (Sources of Evidence), eligibility requirements, and the four phases (application, written documentation, site visit, and decision) are foundational for leaders, stakeholders, and the organization at large to understand. Ambulatory care settings frequently have special data collection measures, geographic distance, and matrixed reporting structures, whether in stand- alone ambulatory care structures or integrated within a larger healthcare organization or system. Using the MPO to navigate the fundamental elements of Magnet eligibility and appraisal may result in cost savings by avoiding rework or potential failure to designate due to infrastructure misalignments or insufficient evidence to support Magnet requirements.

Figure 1. Understanding the Magnet Model

Source: American Nurses Credentialing Center. Used with Permission. All Rights Reserved.

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Table 1. Crosswalk

Note: Ambulatory care data and examples are expected in Magnet appraisal documents; certain standards require ambulatory care examples, where noted in the Magnet Application Manual. © Start, 2021.

The information in this table is intended for educational use and is not to replace or construe interpretation of the ANCC Magnet Recognition program, guidance, or application manuals.

2019 Magnet Application Manual Topics

Items Measured/Discussed/Required

Available AAACN Ambulatory Care Resources/Supports

Demographic Data Collection and Benchmarking

Education, certification, turnover, vacancy • Ambulatory Care NSI Industry Report (guidance on collecting and reporting demographics)

• Nurse Executive Toolkit*

Performance Evaluation and Peer Feedback Process

Require a BSN minimum for nurse managers conducting performance evaluation and overseeing practice

• Nurse Executive Toolkit* • Scope and Standards of Practice for Ambulatory Care

Nursing • Scope and Standards of Practice for Care

Coordination and Transition Management • Scope and Standards of Practice for Professional

Telehealth Nursing • Position Paper on the Role of the RN in Ambulatory

Care Nursing

Shared Decision-Making and Organizational Initiatives

Though not specific, committees, work items, and inclusion of these nurses is expected in all nursing-driven work. Nurses have a seat at the highest decision-making bodies in the organization.

• Nurse Executive Toolkit* • Annual Conference and educational offerings • Scope and Standards of Practice for Ambulatory Care

Nursing • Scope and Standards of Practice for Care

Coordination and Transition Management • Scope and Standards of Practice for Professional

Telehealth Nursing • Position Paper on the Role of the RN in Ambulatory

Care Nursing

Organizational Overview All elements must apply wherever a nurse practices: policies, CNO oversight and visibility, credentialing/privileging, workplace safety, process to address interprofessional conflict, nurse involvement in IRB panels reviewing nursing research studies

• Nurse Executive Toolkit* • Scope and Standards of Practice for Ambulatory Care

Nursing • Scope and Standards of Practice for Care

Coordination and Transition Management • Scope and Standards of Practice for Professional

Telehealth Nursing

Transformational Leadership

TL6: One ambulatory care example required for mentoring TL7: One ambulatory care example required for succession planning

• Nurse Executive Toolkit*

Structural Empowerment SE1EO: One ambulatory care example required for improved patient outcomes associated with participation of RN in organization-level interprofessional decision- making committee SE3, SE4EO, SE5, SE6EO: All nurses required in education and certification count and performance SE8EO: One ambulatory care example required for improved patient outcomes associated with nursing continuing education assessment and related implementation plan

• Scope and Standards of Practice for Ambulatory Care Nursing

• Scope and Standards of Practice for Care Coordination and Transition Management

• Scope and Standards of Practice for Professional Telehealth Nursing

• Position Paper on the Role of the RN in Ambulatory Care Nursing

• Ambulatory Care NSI Industry Report (performance improvement strategies for demographic improvements)

• Certifications and review courses: Ambulatory care nursing, CCTM

• Core Curriculum for Ambulatory Care Nursing • Care Coordination and Transition Management Core

Curriculum

continued on next page

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*AAACN’s Nurse Executive Toolkit will be released in 2021. AAACN = American Academy of Ambulatory Care Nursing ANCC = American Nurses Credentialing Center requirements adapted from ANCC Magnet Recognition Program Manual (2017) APN = advanced practice nurse CCTM = Care Coordination and Transition Management CNO = chief nursing officer EMR = electronic medical record EP = Magnet Exemplary Professional Practice Component EO = Magnet Empirical Outcomes Component IRB = Institutional Review Board NK = Magnet New Knowledge, Improvements, and Innovations Component NSI = Nurse Sensitive Indicators PPM = professional practice model SE = Magnet Structural Empowerment Component TL = Magnet Transformational Leadership Component

Table 1. (continued) Crosswalk

Note: Ambulatory care data and examples are expected in Magnet appraisal documents; certain standards require ambulatory care examples, where noted in the Magnet Application Manual. © Start, 2021.

The information in this table is intended for educational use and is not to replace or construe interpretation of the ANCC Magnet Recognition program, guidance, or application manuals.

2019 Magnet Application Manual Topics

Items Measured/Discussed/Required

Available AAACN Ambulatory Care Resources/Supports

Structural Empowerment (continued)

SE9: If ambulatory nurses are new or APNs are new, evidence of transition to practice program

• Ambulatory Care RN Residency Program • Ambulatory Care RN Residency White Paper

Exemplary Professional Practice

EP1EO: One ambulatory care example required for improved outcome associated with an evidence-based change made by clinical nurses in alignment with PPM EP2EO: Nurse satisfaction, inclusive of all nurses and presented by unit types EP10EO: Turnover rate, inclusive of all nurses EP19EO: Requirement for ambulatory care NSIs, as specified in the manual and tracked by a national database or highest level available EP21EO: Requirement for all ambulatory care areas with a nurse to show patient satisfaction data nationally benchmarked by a national database

• Ambulatory Care NSI Industry Report (performance improvement strategies for engagement, quality, patient satisfaction)

• Nurse Executive Toolkit* • AAACN continuing education to supplement practice:

Telehealth, Covid Care, EMR Strategies, etc. • Scope and Standards of Practice for Ambulatory Care

Nursing • Scope and Standards of Practice for Care

Coordination and Transition Management • Scope and Standards of Practice for Professional

Telehealth Nursing

New Knowledge, Innovations, Improvements

NK6EO: One ambulatory care example required for improved outcome in a care setting associated with a clinical nurses’ involvement in the adoption of technology NK7EO: One ambulatory care example required for improved outcome associated with nurse involvement with design or redesign of work environment

• Ambulatory Care NSI Industry Report (performance improvement strategies for engagement, quality, patient satisfaction)

• Nurse Executive Toolkit* • Scope and Standards of Practice for Ambulatory Care

Nursing • Scope and Standards of Practice for Care

Coordination and Transition Management • Scope and Standards of Practice for Professional

Telehealth Nursing

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Strategies from the Lived Experience of Magnet Model Adoption in an Ambulatory Care Setting

The following paragraphs provide strategies from the lived experiences of Magnet Program Directors and AAACN members.

Transformational Leadership The first and most essential step to authentic

integration of the Magnet model starts with structural design that positions the CNO in connectivity to all settings and roles that practice nursing. Ensuring the CNO has a line of nursing practice oversight and accountability throughout the organization is imperative for all other structures to follow. From this nursing practice ownership position, systems supporting a cultural transformation such as shared governance, performance evaluation and peer feedback, strategic planning, policy creation and standardization, evidence-based practice and research, and strength of professional identity can be integrated. Authentic leadership starting with the CNO can lead to leadership at all levels and in all settings. It must be approached in partnership with other disciplines, not focused solely on achieving Magnet designation but on shared priorities related to patient care.

Often a gap analysis followed by some structured visioning and strategic planning, conducted from an inclusive approach, with all clinical specialties and roles represented, can set the stage for the following years of needed structural redesign. Ensuring these activities are inclusive of both direct-care practitioners and administrative nurses will promote collaboration and diminish hierarchy as a flourishing practice environment is pursued. Planning and executing a multi-pronged communication and feedback process for ongoing improvement through activities such as forums, webinars, development activities, and education, in partnership with an influential and connected shared governance structure, can ensure this culture of ownership and empowerment is hardwired. Promoting activities that develop, mentor, and guide new leaders to succeed in their roles as nurses poised for change management is critical.

Ambulatory care entities seeking to adopt the Magnet model as a blueprint for nursing practice excellence, along with an inpatient setting or independently as a standalone, benefit from this same process of structural design, ensuring either dotted or solid reporting to the organizational CNO. Many organizations are positioning a CNO over their ambulatory care structures to ensure strategies are implemented and sustained. Because many nurses in ambulatory care settings do not report directly to a nurse, processes such as shared governance or performance oversight may not be fully implemented or supported without a designated leader to ensure adoption of this approach. Creating a structure that allows for engagement and empowerment of nursing practice throughout all practice sites requires collaboration with other disciplines and stakeholders. Furthermore, it may be an activity that is occurring due to transformation in health care in different fields and service lines (Peterson & Lovrien, 2015).

Much of the Transformational Leadership portion of the Magnet model focuses on the role of the CNO and other leaders to set strategy and mission, create opportunities for resource advocacy and utilization, as well as succession and mentorship activities (ANCC, 2017). Beyond the requirements of Transformational Leadership, the Magnet process requires demographic data collection at all levels and practice settings of the applicant organization. Nurses with a minimum of a bachelor’s degree in nursing must be in the organizational chart, as managers or directors and higher, cascading from the CNO. They conduct nursing practice oversight, performance evaluations, support for staffing, and empowerment for a shared governance culture (ANCC, 2017). Conducting gap analyses and being familiar with the structures required in the demographic and organizational overview sections of the Magnet process from the earliest moments in an organization’s journey are critical to building nursing excellence throughout (ANCC, 2017).

Structural Empowerment Structural empowerment, defined as access to

information, resources, support, and the

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opportunity to learn and develop (Kanter, 1993), is essential as organizations adopt the ANCC Magnet model and seek authentic ownership of nursing practice in any setting. Aiming to support nursing practice with access to resources and tools from specialty professional organizations, opportunities to attend continuing education such as webinars or conferences, and leveraging internal and external expertise to build nursing staff’s practice acumen are essential. When envisioning shared governance, understanding at the beginning how to operationalize time and resources to make it possible is key. Many ambulatory care organizations are cohorting like clinics into clinic-based committees that report to a coordinating or executive-level committee. Ensuring any structure created in ambulatory care is also included in the organization’s shared governance will promote nursing practice transformation, collaboration, and heightened patient service across the continuum, rather than in silos.

Development of policies that support advancing professional development, pursuit of specialty certification, and higher degrees within nursing are processes that continue to empower nursing staff to be equipped as full partners and leaders in any environment. Regular assessment of learner needs and strategic deployment of continuing education to meet these needs ensures nursing is abreast of recent changes to the practice environment. Supporting transition to practice throughout all roles and settings, including advanced practice nurses and administrative nurses, in addition to new graduates and other experienced nurses changing practice settings, will support retention, engagement, and improved patient outcomes (Goode et al., 2016).

Aligning empowerment structures with community, social, and diversity-based strategies promotes a nursing staff that is valid in a healthcare setting that is rapidly evolving. Also, empowerment of staff involves recognition of exemplary practice and achievement of positive patient outcomes. Seeking meaningful structures to recognize nursing can support engagement and increased practice ownership (AACN, 2005; Grant et al., 2020).

Exemplary Professional Practice Understanding and integrating a professional

practice model (PPM) to guide nursing practice identity is important as job descriptions, peer evaluation, awards, and committee work is pursued (Hossli et al., 2018; IOM, 2010; Wadsworth et al., 2016). Ensuring the ambulatory care setting is involved in PPM selection and adoption is an essential part of structural empowerment and must be pursued with subsequent patient outcomes. Ambulatory care settings adopting the Magnet model can create or implement a PPM and utilize it to guide clinical advancement, performance, peer evaluation, and other nursing practice activities (Hossli et al., 2018).

With practice identity enculturated, nurses in ambulatory care pursuing Magnet adoption can seek to work collaboratively with other stakeholders and nursing departments to support staffing, value-based care delivery, interprofessional collaboration, and patient outcomes. Patient outcomes can be tracked at both an internal and national benchmarkable levels to demonstrate exemplary professional practice. AAACN has contributed to developing nurse-sensitive indicators that support outstanding professional practice (Start et al., 2018; Start et al., 2016).

Mature nursing practice has full ownership and accountability for patient outcomes (Clavelle et al., 2016) and is supported by regular, formalized data analysis and dashboard tracking (Wilbanks & Langford, 2014). Using patient outcomes and related benchmarks can help develop efficient and value-based staffing in the ambulatory care setting. Empowering nurses to pilot and test various care delivery interventions and use data to track success or persistent gaps expands the critical thinking and research-based understanding of nursing staff.

New Knowledge, Innovations, and Improvements

An empowered, flourishing nursing staff is accountable for full ownership of the discipline and utilizes scientific knowledge to promote evidence-based changes to practice and seeks to

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grow new knowledge where gaps exist (ANA, 2010; Clavelle et al., 2016; IOM, 2010). Magnet applicant organizations must show evidence of at least one open nursing research study and one completed nursing research study. Numerous other examples of evidence-based practice adoption and promotion throughout the organization must be documented. As nurses become more comfortable with scientific inquiry, searching evidence for answers to practice questions, and improving practice that elicits positive patient outcomes, new knowledge, improvements, and innovations occur. Supporting a learning and appreciative-based approach to improving workflow and redesign of care and the leverage of technology also show nursing staff’s willingness to improve and grow discipline- specific contributions to care.

Connecting ambulatory care nursing staff to resources that exist to support research and evidence-based practice will promote continuous improvement in patient outcomes. Support for tracking and disseminating best practices can further the nursing community beyond the original healthcare organization’s walls. Strategies such as lean methodology, improving nurses’ ability to conduct business case proposals, and linking to constant data analysis will promote nursing practice improvements that synergize organizational priorities relative to efficiency and value (Brown, 2009; Brown et al., 2020).

Empirical Outcomes The fifth component, Empirical Outcomes, is

weaved through the other four components as the “so what” factor of any nursing structure or process. Empirical outcomes require pre and post- data points that prove a nursing intervention, structure, or process has positive results on nursing practice, patient care environment, or patient outcomes (ANCC, 2017). Ambulatory care nurses working to show evidence of impact through interventions, structures, or processes in the other components should be organized to collect pre and post-data when initiating work. Tying metrics to strategy, creating dashboards at clinic, department, service line, and organizational levels can help analyze the impact of ongoing performance improvement. Mentorship, especially

as new shared governance activities seek to integrate metrics into their work, is vital to assist nurses in performance improvement, evidence- based application, and ongoing tracking of outcomes.

Conclusion

As healthcare shifts from an acute, disease, and episodic-based model to health, community, and continuum-focused interventions, ambulatory care nurses are essential in this transformation and success. Leveraging the ANCC Magnet model as a blueprint for a journey that leads to improved patient outcomes and care of the nursing workforce can ensure that transformation is achieved. Significant support to develop structure, connect nursing practice across the continuum, and empower new generations of nurses into other settings besides acute care has the potential to propel nurses in ambulatory care practice to the full extent of their education and license. This strategy can develop the discipline and fulfill nursing’s contract with society. $

Rachel Start, MSN, RN, NEA-BC, FAAN Director Ambulatory Nursing and Nursing Practice Rush Oak Park Hospital Oak Park, IL Rebecca Graystone, MS, MBA, RN, NE-BC Vice President American Nurses Credentialing Center Silver Spring, MD NOTE: The “Perspectives in Ambulatory Care” column makes sense of today’s changing ambulatory care market. It 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 AAACN, please visit www.aaacn.org; email [email protected]; or call (800) AMB-NURS.

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