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Ambulatory care nursing: growth as a professional specialty.

HISTORICALLY, THE outpatient setting was the "professional home" of physicians. They saw the majority of their patients in their offices and referred them for other services or levels of care, as needed. Registered nurses were few as the system was physician driven. However, fiscal caps for hospital care and technological advances moved patients from inpatient venues into the ambulatory care setting. Patients required higher levels of care than in the traditional outpatient settings, and the ambulatory venue saw a growth in the number of professional nurses. Over the past 3 decades, ambulatory care nurses have grown in number and in their ability to distinguish themselves as a unique professional specialty. A definition of their practice and the development of a conceptual framework are hallmarks of this distinctive professional progression.

Definition of Professional Ambulatory Care Nursing

Professional ambulatory care nursing is a unique domain of specialty nursing practice focusing on health care for individuals, families, groups, communities, and populations. Ambulatory care nurses practice in settings distinctive from other nurses. They practice in primary and specialty care outpatient venues, non-acute surgical and diagnostic outpatient settings in the community, and during telehealth nursing encounters that occur in centers, medical offices, or by individual nurses in the home.

Characteristics of ambulatory care nursing. Ambulatory care nursing is characterized by registered nurses caring for high volumes of patients in short periods of time (always less than 24 hours), often dealing with issues in each individual encounter that can be unknown and unpredictable. Ambulatory care nurses address, in partnership and collaboration with other health care professionals, patients' wellness, acute illness, chronic disease, disability and end-of-life needs. As nurses, they are responsible for patient advocacy, coordination of nursing and other health services, implementation of nursing judgment and services, and continuity of care.

Ambulatory care nursing includes those clinical, organizational, educational, and research activities engaged in by registered nurses for and with patients (individuals, groups, and populations that seek care for health-related problems and concerns or seek assistance with health maintenance and/or health promotion). Patients in ambulatory care predominantly engage in self-care and self-managed health activities or receive care from family/significant others outside institutional settings. The nurse assists and influences the patient and/or caregiver in making informed decisions about self-care and health behaviors.

Ambulatory nurse-patient encounters. Ambulatory care nursing services are episodic, and occur as a single encounter or a series of encounters over hours, days, weeks, months, or years. Despite time-limited episodic encounters, ambulatory care nurses generally have long-term relationships with patients, families, and caregivers, teaching and translating collaborative plans of care into doable activities to meet health needs. Ambulatory nurse-patient encounters take place in health care facilities, in telehealth service situations, electronic communications, as well as in community-based settings, including outpatient office systems, private medical offices, freestanding clinics, schools, workplaces, or homes.


Conceptual Framework

The second hallmark of growth as a profession was establishing and then expanding the conceptual framework for ambulatory care nursing. In 1998, American Academy of Ambulatory Care Nursing (AAACN) expert members were called together in a "think tank" session to collaboratively develop a conceptual framework for ambulatory nursing practice. Using a nominal group approach, the members identified two major concepts that interplay in the specialty: "patient" and "nurse."

In 2009, the AAACN membership revisited the original framework and decided an expansion was relevant. The conceptual diagram (see Figure 1) extends the original 1998 framework and diagram, identifying three major concepts: (a) patient, (2) environment, and (3) nurse. The framework was posted on the member web site, and the members of AAACN reviewed and commented on the proposed changes. Over 85% of the members responding indicated "environment" was critical to their practice and defining it was important. The members made comments that were incorporated into the final framework statement.


Inherent within the concept of "patient" is each individual is unique; functions holistically as a biological, psychosocial, and spiritual being; and is the center of patient-nurse interactions. "Patients" in the ambulatory care setting refers to individuals, families, caregivers/support systems, groups, and populations that approach the health system in a variety of circumstances or health states. Patient health states are categorized as "wellness or health," "acute illness," "chronic disease and/or disabled," and "end of life."

Generally, patients initiate contact with the ambulatory care system to meet their wellness concerns and health needs. Patients maintain control of the encounter and treatment with the nurse acting in a consultative role.


The second concept, "environment," helps define ambulatory nursing practice, setting it apart from other nursing specialties. In addition to the nurse-patient relationship and interactions, ambulatory care nurses must address organizational, social, economic, legal, and political factors, both within the health care system and also in the external health care environment. The internal care delivery environment is where patients initially access and receive care and where the nurse actually practices. The external environment refers to both the geographic locale of the specific health care practice and contextual factors in the greater ambulatory care environment.

Internal care delivery environment. The ambulatory nursing care delivery environment is dynamic and diverse, including a broad scope of practice settings where patients seek health care treatment and where the professional nurses function. The ambulatory nursing care delivery environment can include such settings as an individual physician's office, group office practices, freestanding or hospital-based clinics, infusion centers, nursing clinics, ambulatory surgery or procedure centers, telehealth centers, care coordination organizations (case, care, and disease management organizations), multispecialty health organizations (e.g., health maintenance organizations), military bases, or comprehensive, integrated health care systems.

External environment. The external geographic locale and contextual factors often influence an individual ambulatory health care setting's mission, patient population, and practices. For example, rural and urban outpatient settings most likely address different patient needs and have different requirements and resources.

The external contextual factors include, but are not necessarily limited to, the current health policy, governmental laws, professional practice regulations, accrediting agency standards, health care financing systems, and advances in science and technology. Emerging scientific knowledge and diagnostic and treatment technologies as well as the information management systems that support and coordinate patient care through virtual information exchange all influence the practice of ambulatory care nursing significantly. Further, each health care delivery setting is affected by general circumstances, such as socioeconomic conditions, cultural considerations, safety, transportation, pollution, disasters, epidemics, and/or pandemics, etc.


The third concept, "nursing," defines professional ambulatory care nursing as a unique domain of specialty nursing practice. It is characterized by professional nursing staff responding rapidly to high volumes of patients in a short period of time, often dealing with issues that are unknown and unpredictable. Nurse-patient encounters occur on an episodic basis, but relationships often last months or years.

The scope of professional ambulatory care nursing is dynamic, evolving continually in response to changing societal and organizational needs and the expanding knowledge base of ambulatory care nursing's theoretical and scientific domains (American Nurses Association, 2004).

The research of Haas and Hackbarth (1995) helped delineate that ambulatory care nursing may be categorized into three major roles: clinical, organizational/systems, and professional.

While defined separately, these roles are not necessarily mutually exclusive and frequently overlap. It is this overlap of roles that brings challenges and professional growth, adding dynamism, learning, and diversity to ambulatory nursing practice.

Clinical nursing role. Ambulatory care nurses practice clinically by using the nursing process in their specific specialty role. Clinical nursing, both in the clinic setting and when providing telehealth services, requires expert nursing process skills: assessment of patient problems and concerns in limited time frames; the ability to critically analyze and integrate subjective and objective data related to patient concerns and conditions; capabilities to identify problem(s) and pertinent goals; competence in planning appropriate nursing care; the ability to implement suitable, evidence-based nursing interventions; and appropriate evaluation of patient outcomes. The ambulatory care nurse also applies the nursing process in assessing, analyzing, planning, delivering, and evaluating care of patient groups and populations.

The clinical role activities also encompass:

* Patient advocacy.

* Compassion, caring, and emotional support.

* Sensitivity to the patient's cultural, ethnic, and age-related needs.

* Referral of patients to optimal health services.

* Education and support of self-care behaviors to promote health and prevent disease and secondary complications.

* Performance of nursing procedures.

* Consultation and collaboration with professional colleagues.

* Careful, complete documentation of care given.

* Management of clinical nursing care and practices and their outcomes.

Inherent in the clinical role is the use and development of appropriate, evidence-based nursing knowledge and health care protocols.

Organizational/systems role. Ambulatory care nurses practice within the organizational/systems role when they administer and coordinate resources and direct clinical and organizational activities and workflow within their health care setting.

The organizational role has multiple dimensions: staffing, workload and competency concerns, workplace regulatory compliance and risk management, health care fiscal management, legal and regulatory issues, organizational cultural competence, quality management systems, the application of health informatics systems, use of diagnostic and treatment technologies, conflict management, structuring customer-focused systems, and patient and health advocacy within the organization and across the community.

Professional role. Ambulatory care nurses function within the professional role as they practice according to professional, ethical, and organizational standards. The professional role also requires the use of evidence-based techniques, the evaluation of the outcomes of nursing practice, the lifelong expansion of ambulatory nursing knowledge and skills of self as well as contributing to that of other staff, contribution to the advancement of the nursing profession and the specialty, and the continuous improvement of the quality of health care practices and outcomes. As professionals, ambulatory care nurses are expected to demonstrate leadership skills within the health care organization, in the community, and across the nursing profession.

While some aspects of all three roles are part of every ambulatory care nurse's practice, emphasis on one of the roles usually exists depending on the specific role and position of the nurse within the practice setting. For example, the telehealth services and clinical nurses will most likely focus largely on the clinical role requirements of their job descriptions, but organizational (unit workflow concerns) and professional role requirements (education or research) may also be expected depending on the organization's structure and the unique situation.

The requirements for quality nursing care in ambulatory settings have expanded and will continue to do so. But ambulatory nurses, with the support of AAACN, their professional organization, have demonstrated their ability to advance, articulating their professional practice theoretically and conceptually as well as in practice interventions.


American Academy of Ambulatory Care Nursing (AAACN). (2010). Scope and standards of practice professional ambulatory care nursing (8th ed.). Pitman NJ: Author.

American Nurses Association. (2004). Nursing scope and standards of practice. Silver Spring, MD: Author.

Haas, S.A., & Hackbarth, D.P. (1995). Dimensions of the staff nurse role in ambulatory care: Part II--Comparisons of role dimensions in four ambulatory settings. Nursing Economic$, 13(3), 152-165.

MARGARET FISK MASTAL, PhD, RN, is Past President, The American Academy of Ambulatory Care Nursing, and Chair, Steering Committee for The Scope and Standards of Professional Ambulatory Care Nursing Practice, Alexandria, VA.

NOTE: This column is written by members of the American Academy of Ambulatory Care Nursing and edited by Candia Baker Laughlin, MS, RN, C. 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; E-mail:; Web site:
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Title Annotation:Perspectives in Ambulatory Care
Author:Mastal, Margaret Fisk
Publication:Nursing Economics
Geographic Code:1USA
Date:Jul 1, 2010
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