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Introduction   

According to the American Academy of Ambulatory of Ambulatory Nursing (AAACN), “professional ambulatory care in nursing is a unique domain of specialty nursing practice that focuses on health care for families, groups, communities, and populations” (1). These nurses practice in outpatient settings such as clinics, primary and specialty care offices, outpatient surgery, and diagnostic ambulatory settings. Other roles include case/disease management, triage (often remotely), and telehealth for nurse practitioners. 

History 

In 2011, the AAACN published an initial statement that outlined the ambulatory nurse role. A second version was published in 2016, quickly followed by a manuscript in 2017, further classifying the role (2). These statements identified and clarified the role as a broad category of nursing services rendered within outpatient areas (2). Since our healthcare system continues to focus on the importance of health and wellness, a shift in nursing care to the outpatient setting is necessary. We see decreasing hospital stays and advancements in non-invasive procedures, and with advanced technology and data analysis, nursing needs to shift some of its practice to these ambulatory settings. 

Case Study: Author Reflections 

As a registered nurse for over 38 years, I found myself in the 1990s working in an urgent care setting. At that time, it was so new to me. I had never heard of urgent care. We triaged patients by phone and made appointments for that day. It was challenging because we did not care for critical care patients, per se, but we often had critical patients walk in. We would stabilize these patients and then send them by ambulance to an area hospital. One case was a young person who walked in saying they had been having chest pain for an hour. We did an EKG, put in an IV, and gave them aspirin and morphine while someone was calling the ambulance. When the medics arrived, we gave a report. This became my favorite practice.   

In between, I also worked as a case manager, first for an insurance company, then for a Physician Hospital Association (PHO), and then for an Accountable Care Organization (ACO). I was at the forefront of ambulatory care before it was considered a specialty. 

Often, nurses who traditionally work in hospitals in certain specialties, such as endoscopy and day surgery, transition to the outpatient setting and continue their specialty practice. 

Ambulatory Centers 

So, what are ambulatory centers, and where are they? Many ambulatory centers are part of hospital systems or can stand alone as retail clinics. They are places where patients can access care as an outpatient (3). The American Hospital Association (AHA), has defined these eight areas as belonging to ambulatory centers (3): 

• Through medical websites and patient portals 

• Mobile care in converted vans well-equipped for patients who cannot access care. 

• Retail clinics inside stores where patients can see a nurse practitioner or physician’s assistant 

• Urgent care centers that offer some lab assessments such as flu, covid 19, urine testing for urinary tract infections, and pregnancy and smears for infections or sexually transmitted diseases. They also perform screening x-rays. 

• Free-standing emergency departments fall somewhere between the emergency department and urgent care. 

• Workplace clinics such as Occupational health to keep their workers healthy while maintaining productivity 

• Primary care clinics, often staffed by mid-level practitioners  

• Specialty and high-tech clinics encompassing diabetes management, endoscopy, infusions, cancer care, and interventional radiology  

• Outpatient surgical centers such as minor procedures  

• Case and Disease Management 

Nursing Roles 

As indicated earlier, the AHA states that nurses have many roles in this new specialty. We know that nurses are integral to patient care, yet as long as I have been an RN, there has been a shortage of nurses. Some of this is due to the many options people have today in science, technology, education, etc., as well as the lack of nurse educators. These shortages have caused many of us to be unhappy and look for alternatives to inpatient nursing as we cannot give patients the excellent care and time that we used to.   

Many “seasoned” and newer nurses are moving towards ambulatory care because of the shorter hours, fewer mandates, and better organizational support. About 20% of nurses have left the profession due to retirement or staffing issues after the COVID-19 epidemic. A study from the International Journal of Nursing Studies Advances shows that nurses are much happier in the outpatient setting, and patient outcomes have improved, reducing costs (4). 

As trained nurses, we emphasize population health, wellness, and “holism” to provide more individual care, population health and support, and self-management of our patients in these settings. As a former case manager, I believe case management is critical. These nurses work with the patient to provide education, access to services, and disease management for their cohort of patients, usually at home or in the hospital. They will often assist with discharge planning.  They know what facilities and agencies are covered by each patient’s insurance (2). They also follow the patient remotely by telephone or video conferencing, at whatever level of care patients are in the system. 

With technological advances, nurses can provide telephonic visits and triage, possessing core informatic abilities to influence patient outcomes and reimbursement (2). Newer reimbursement models also “create the potential to untether nurses from a system where they are bundled into labor costs” (2).   

The ambulatory model recognizes nurses’ contributions to health care (2). In this way, we can reach previously unreachable populations and move towards our ability to receive payments from insurers and the like for services rendered. The AAACN has also defined the characteristics of the ambulatory nurse, stating, “the ambulatory nurse focuses on patient safety and quality nursing care by applying appropriate nursing interventions, such as identifying and clarifying patient needs, performing procedures, conducting health education, promoting patient advocacy, coordinating nursing and other health services, assisting the patient in navigating (the) health care system, and evaluating patient outcomes” (6). 

Case Study: Author Reflections 

Another nursing role I found fascinating was the outpatient pre-hospital discharge nurse. My mom had congestive heart failure and was allowed to go home early and receive follow up care for three days by an RN who came to her home. I was there one day when mom’s nurse arrived. I was very impressed by her assessment of my mom. Mom was instructed to record her daily weight, how often she urinated, and diet for those three days.   

The nurse then thoroughly inspected for edema, heart, bowel, and lung sounds, and complete vital signs. The nurse also recorded her findings on her laptop in Mom’s medical record so the cardiologist could review them. Shortly after the nurse left, the cardiologist called my mom, gave us an update, and answered our questions. I believe this role gives nurses greater autonomy, utilizes our excellent clinical skills, lowers costs for the hospital, and, most of all, allows patients to continue recovery in their own homes, which we know is where they prefer to be. 

Above all, the AAACN states that nurses in ambulatory settings must have critical thinking skills and judgment to provide quality care across the lives of patients, families, and the community (6). 

Patient Effectiveness and Satisfaction 

So, how does the patient fare in this model of health care? As our healthcare system shifts from illness to wellness and preventative care, nurses are the most likely professionals to be involved in this process. Nurse practitioners work in clinics such as “The Minute Clinic” within pharmacies and other agencies as business occupational practitioners; this facilitates visits for patients who cannot get a rapid appointment with their doctors or have minor illnesses. With advanced technology where patients can log on to portals to ask questions and get advice from nurses or see nurses in their homes or other outpatient settings, this practice has given patients greater control of their healthcare. This is especially helpful for those who live in rural areas and cannot access healthcare easily.    

A study by Kathleen Armstrong et al. (5) states that patients are pleased with telephonic follow-up after some surgeries. This is important since the nurse can give the time most doctors do not have to answer questions, get and provide feedback, enlist the patient to keep journals of their recovery, and assess if there are any issues. 

Case Study: Author Reflections 

For example, I work as a public health nurse for the local county health department. In this role, I perform blood pressure and glucose checks for clients at our local food pantry two Thursdays a month. I have enrolled over 20 patients in the clinic who come faithfully for their interval checks between doctor appointments. Each patient receives a booklet with their results and, after ten visits, a gift card to a local grocery store. We also have a nutritionist or dietician in the same space to educate and provide our clients with healthy recipes and sample tastings.  

Another aspect of my public health nursing is involvement in flu and COVID clinics. During the pandemic, my twelve nurse colleagues and I vaccinated over 38,000 people in the first six months of receiving the vaccine. We also perform these clinics in senior and lower-income housing, nursing facilities, and schools.   

Clients are pleased and grateful for these clinics because we have the time to educate and advise them on health and wellness and answer any questions. This gives them peace of mind and a document for doctor’s appointments. It is also cost-effective and is advocated by providers in our system since the clients are not seen in their offices for these essential checks as often as we provide them. 

The clients love this system because, in many cases, we come to them instead of them coming to us. Patients also prefer urgent care centers because they are faster than the emergency department and much less costly when not admitted to the hospital. It is an excellent place for nurses as our skills are still being used, and we can give the patient more time for education on how to use any equipment, what their diagnosis means, and how to follow up. We use many nurse practitioners in this setting as well.   

A study by Julianne K. Evangelista et al. states that pediatric nurse practitioner-managed cardiology clinics are a strategic solution for enhancing patient access to care while facilitating elevated quality care and gaining high patient and family satisfaction. This model demonstrates the expanded use of advanced practice nurses (7). 

A Veterans Administration pilot program for nurses in a southern U.S. community state that changing the healthcare system from episodic care to preventive chronic illness care is essential (8). The data collected indicated a cost lowering related to readmissions of $ 75,633.16 and a combined improvement of 95% related to the possibility of an event including death or readmission (8). The qualitative data reported positive patient outcomes, including weight loss, alcohol cessation, decrease in hospital admissions, and improvement in the health of patients who have diabetes (8). 

Education and Certification 

So, how do we prepare for this new specialty? AAACN states that RNs “require specialty training and orientation for competency in ambulatory practice” (2). AAACN also provides the scope and standards of ambulatory nursing. Some universities are now adding this specialty to their curriculum. There are also online certifications, test guides, and on-the-job training for new ambulatory nurses. Some agencies require a BSN or MSN (NPs), but an ADN may be accepted in some cases.  

Certification will depend on the agency, but the AAACN recommends it. To be eligible to take the AAACN exam for certification, the RN must:  

• Must have a current RN unencumbered license 

• Have been a practicing RN for two years in any specialty 

• 2,000 hours as an ambulatory RN  

• 30 hours of continuing education in 3 years 

It usually takes 2-4 years to meet all requirements, and the American Nurses Credentialing Center (ANCC) provides certification exams (10). Once certified, the RN’s title changes to RN AMB-CN. 

Future of Ambulatory Nursing 

Ambulatory nursing is ever evolving. These RNs focus on “assessment of all aspects of healthcare including physical, biological, social, and environmental influences on health” (2). They enrich the care given by other providers to improve patient outcomes and reduce negative outcomes using specific skills and education. They engage in population health, reduce costs and have more job satisfaction all which promote improved patient outcomes.   

Since the onset of managed care and the Affordable Care Act, the Center for Medicare and Medicaid Services (CMS) has focused on a different payment system instead of fee-for-service.  A new model of reimbursement recognizes ambulatory nursing as a distinct practice rather than being part of the labor system (2). The AAACN acknowledges that patients’ needs in the outpatient setting differ from those of patients in the inpatient setting.  

As nurses, we must continue to advocate for our profession by contributing to and preparing our future nurses, to ensure they are recognized for their skills (2).  

The American Nurses Association (ANA) states that CMS will reimburse ambulatory nurses who work inpatient or in ambulatory settings, depending on who employs them. For example, a physician or entity who employs nurses can be refunded for nursing care under their allowable benefits. Also, nurse practitioners are now being reimbursed under “eligible professional services” (2). 

The Commission for Nurse Reimbursement (CNR) hopes to develop compensation for nurses across the continuum. The current system has created “significant barriers” to nursing retention, contributing to the nursing shortage and discontentment (9). 

Conclusion

We have introduced ambulatory nursing as a newer specialty with certification and the ability to practice outside the hospital. Since healthcare is focusing more and more on education and illness prevention, nurses are at the forefront of this practice. In nursing school, we were all taught about seeing the whole patient, not as an illness or disease, but as the social, psychological, biological, and support systems each patient has or exhibits. In response to population/community health needs and cost management, the system now recognizes outpatient care’s impact. Nurses can bring their expertise to these settings and spend more time on patient assessment, planning, implementation, and evaluation, as well as educating and supporting our patients. We can access other patient services and use advanced technology to arrange virtual visits with patients in their homes. This brings higher patient satisfaction, better outcomes, and reduced costs. The wish to recognize nursing services as a highly skilled and professional practice may gain a better reimbursement system for us all. 

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