Caroline V. Coburn, DNP, APRN, ANP-BC, Associate Clinical Professor, Emory University
Updated: 03/28/24
Background: The challenge of preparing BSN student nurses with skills and competencies needed for practice in an increasingly complex healthcare system has been noted. Healthcare facilities describe new graduates who lack the expected skills and competencies even at a beginning nurse level, and schools of nursing find that the limited availability of clinical sites increases the obstacles to helping students make the clinical-didactic connection. One method for addressing this challenge is through simulation that allows students to practice and demonstrate clinical competencies in a safe environment. In our accelerated BSN nursing program, we provide ambulatory care simulations that exemplify three key components of ambulatory care nursing: telehealth, primary care, and home health. For these simulations, we evaluate our students in alignment with the American Association of Colleges of Nursing Essentials, using a modified Lasater scale used by our primary clinical partner in new graduate residency. The Essentials: Core Competencies for Professional Nursing Education detail the domains, competencies, and sub-competencies needed for pre-licensure students to advance to practice. The modified Lasater scale is used to evaluate new graduates for clinical readiness. The combination of these resources allows us to evaluate these last-semester pre-licensure students for significant gaps in competency.
Method: Students are single or in pairs for each simulation. Prior to the simulation, they are provided with resources and an overview of expectations based on the Lasater framework of noticing, interpreting, responding, and reflecting. As they proceed through the simulation, clinical faculty from the ambulatory care setting and/or standardized patients interact as patients. Separate faculty are designated as observers only. Observer faculty use the Lasater tool as modified by our clinical partner and the students are rated as beginning, developing, accomplished, or exemplary in both physical skills and clinical judgment. After the simulation, both faculty and standardized patients provide immediate feedback and review of the students’ performance. The students submit a post-simulation analysis/reflection on their perceived strengths and weaknesses and ways they expect or intend to improve. If remediation is necessary, it is in the form of video review, faculty discussion, and possibly repeated simulation.
Evaluation: Scores from the faculty evaluation are used in post-simulation discussion with the students of areas needing improvement. They also are reviewed to identify students who, in any category, do not meet the beginning level. These students receive a written evaluation, taking into consideration their comments in the self-reflection assignment. This provides a tool for the student to address areas of concern. If students fall below beginning level on multiple categories, clinical faculty may assign remediation. Analysis of the percentages of students needing remediation or follow-up also will inform potential curricular modifications to meet the needs of our clinical partners who receive new graduates.
Implications: Communication, prioritization, and clinical reasoning are approached in a different manner in ambulatory care and require guided direction toward competency. In collaborating with practice partners, ambulatory care faculty and clinical instructors can develop simulation experiences and evaluation that will inform academic preparation and assist in clinical competency for newly graduated students.
Method: Students are single or in pairs for each simulation. Prior to the simulation, they are provided with resources and an overview of expectations based on the Lasater framework of noticing, interpreting, responding, and reflecting. As they proceed through the simulation, clinical faculty from the ambulatory care setting and/or standardized patients interact as patients. Separate faculty are designated as observers only. Observer faculty use the Lasater tool as modified by our clinical partner and the students are rated as beginning, developing, accomplished, or exemplary in both physical skills and clinical judgment. After the simulation, both faculty and standardized patients provide immediate feedback and review of the students’ performance. The students submit a post-simulation analysis/reflection on their perceived strengths and weaknesses and ways they expect or intend to improve. If remediation is necessary, it is in the form of video review, faculty discussion, and possibly repeated simulation.
Evaluation: Scores from the faculty evaluation are used in post-simulation discussion with the students of areas needing improvement. They also are reviewed to identify students who, in any category, do not meet the beginning level. These students receive a written evaluation, taking into consideration their comments in the self-reflection assignment. This provides a tool for the student to address areas of concern. If students fall below beginning level on multiple categories, clinical faculty may assign remediation. Analysis of the percentages of students needing remediation or follow-up also will inform potential curricular modifications to meet the needs of our clinical partners who receive new graduates.
Implications: Communication, prioritization, and clinical reasoning are approached in a different manner in ambulatory care and require guided direction toward competency. In collaborating with practice partners, ambulatory care faculty and clinical instructors can develop simulation experiences and evaluation that will inform academic preparation and assist in clinical competency for newly graduated students.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Alicia Bosse, MBA, BSN, CMSRN, AMB-BC, Clinical Nurse Educator, UT Southwestern Medical Center
Updated: 03/07/24
A large academic medical center sought to expand internal capabilities of the licensed vocational nurse (LVN) to include intravenous (IV) therapy in the ambulatory care setting. Historically, LVNs were restricted from practicing IV therapy per institutional policy. Feedback from ambulatory care clinics indicated that allowing LVNs to provide IV therapy would offer multiple benefits. First, the change would enable LVNs to initiate an IV in an emergent situation rather than delay care until a registered nurse (RN) arrives. Clinics with limited RN staff would be able to utilize LVNs to start IVs, allowing the RN to focus on other tasks which cannot be delegated, such as telephone triage. Lastly, expanding LVN functionality to encourage height of licensure practice would increase job satisfaction and maximize budgetary resources.
When considering this concept, guidance on practice standards was sought from governing and professional organizations. The state board of nursing (BON) recognizes that LVN educational programs do not mandate instruction on IV principles or techniques. Therefore, the BON recommends that LVNs not engage in IV therapy without successfully completing a knowledge and skills validation course. The state BON does not define or set qualifications for what constitutes a valid training program.
Following a shared governance model, a proposal was presented to an ambulatory care practice council to enhance LVN practice to include peripheral IV therapy. Approval was granted with the stipulation that completion of a comprehensive training course followed by competency validation by an RN preceptor would be required. It was also specified that IV therapy tasks performed by LVNs would be limited to IV initiation, fluid administration, and IV discontinuation and exclude IV medication administration.
The ambulatory care clinical education department developed and implemented an IV therapy training course in accordance with established nursing practice standards. Topics addressed in the training included scope and legalities, infection prevention, anatomy and site selection, contraindications, IV initiation and discontinuation processes, fluid infusion, documentation, potential complications, and patient-specific considerations. To maximize learner outcomes, the evidence-based curriculum included an interactive didactic presentation followed by hands-on skills practice.
A post-course evaluation was utilized to assess the effectiveness of the training. The average pre-course confidence rating with IV therapy skills was 1.83 on a 1-5 Likert scale with 1 indicating “no confidence” and 5 indicating “extremely confident.” Post-course confidence more than doubled to an average rating of 4. Increased confidence was reported as the main benefit of the course, followed by the ability to provide better patient care. 100% of nurses who completed the evaluation reported a significant increase in job satisfaction.
The original intent of the program was to train LVNs to perform IV therapy; however, this course has proven to serve a broader staff population. Ambulatory care RNs have also attended the course to expand their existing knowledge and strengthen their precepting ability. The course implementation was a success, and the goal is to continue offering the course regularly to support quality patient care, increase employee satisfaction, and diversify staff skills.
When considering this concept, guidance on practice standards was sought from governing and professional organizations. The state board of nursing (BON) recognizes that LVN educational programs do not mandate instruction on IV principles or techniques. Therefore, the BON recommends that LVNs not engage in IV therapy without successfully completing a knowledge and skills validation course. The state BON does not define or set qualifications for what constitutes a valid training program.
Following a shared governance model, a proposal was presented to an ambulatory care practice council to enhance LVN practice to include peripheral IV therapy. Approval was granted with the stipulation that completion of a comprehensive training course followed by competency validation by an RN preceptor would be required. It was also specified that IV therapy tasks performed by LVNs would be limited to IV initiation, fluid administration, and IV discontinuation and exclude IV medication administration.
The ambulatory care clinical education department developed and implemented an IV therapy training course in accordance with established nursing practice standards. Topics addressed in the training included scope and legalities, infection prevention, anatomy and site selection, contraindications, IV initiation and discontinuation processes, fluid infusion, documentation, potential complications, and patient-specific considerations. To maximize learner outcomes, the evidence-based curriculum included an interactive didactic presentation followed by hands-on skills practice.
A post-course evaluation was utilized to assess the effectiveness of the training. The average pre-course confidence rating with IV therapy skills was 1.83 on a 1-5 Likert scale with 1 indicating “no confidence” and 5 indicating “extremely confident.” Post-course confidence more than doubled to an average rating of 4. Increased confidence was reported as the main benefit of the course, followed by the ability to provide better patient care. 100% of nurses who completed the evaluation reported a significant increase in job satisfaction.
The original intent of the program was to train LVNs to perform IV therapy; however, this course has proven to serve a broader staff population. Ambulatory care RNs have also attended the course to expand their existing knowledge and strengthen their precepting ability. The course implementation was a success, and the goal is to continue offering the course regularly to support quality patient care, increase employee satisfaction, and diversify staff skills.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/07/24
Registered nurse (RN)-led annual wellness visits (AWV) offer Medicare patients an opportunity to collaborate with a member of their care team to evaluate preventative care gaps at no cost to them. By completing these visits yearly, care gaps can be closed, and preventive services can be offered to these most vulnerable patients, thus maximizing their health and decreasing their healthcare costs. According to Farford, et al. (2020), “The RN-led AWV is an effective way to assist Medicare beneficiaries in meeting their preventive needs while allowing physicians more time to focus on chronic and acute needs.” However, despite valuing the AWV and understanding the components for documentation, the rate of non-billable visits to Medicare was 57% in January of 2023. There were old templates in Epic that did not prompt the RN to enter all the required information for a visit to be considered billable to Medicare. This gap in documentation was discovered at the same time nursing was being asked to increase the number of AWV from 5% to 24% across primary care. Nursing leaders collaborated to create an AWV express lane in Epic and deleted old, non-compliant templates. Informational sessions were held to discuss AWV billing requirements and the importance of AVWs and to provide education to introduce the express lane. Post-implementation measures showed intervention success with AWV non-billable visits decreasing from 57% to 17%. Future efforts to enhance AWVs include increasing nurse staffing levels to allow additional visits to be completed, educating patients and the public regarding the importance of the AWVs, enhancing motivational interviewing skills for the RN, and ensuring we remain up to date on changes to Medicare requirements.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/07/24
The antimicrobial stewardship program (ASP) is designed to help optimize antimicrobial use across the spectrum of inpatient and outpatient services. The penicillin challenge initiative falls under this umbrella. ASP provides advice in selecting the most appropriate antimicrobial agent, dose, and duration to achieve the best clinical outcome with the fewest possible side effects. Unaddressed penicillin allergies are a public health issue. 10% of US patients have a penicillin allergy label, and fewer than 1% have an actual allergy with clinical significance according to the CDC. Use of broader spectrum antibiotics may be less effective, leading to antibiotic resistance and increased incidence of c-diff. Adherence to using the best antimicrobial agents has tremendous individual and global health outcome implications. Penicillin category drugs are among the safest, most-effective, least- expensive antibiotics.
The objectives of our project were: 1) Describe the allergy response and how it is used to stratify risks. 2) Identify the process in which the best practice advisory (BPA) is flagged in Epic and the subsequent plan of care. 3)
Recognize the health care impacts of de-labeling penicillin allergic patients.
The penicillin challenge is a safe, cost-effective, timely process to improve a public health issue directly impacting patient outcomes and health care costs globally. Participation of infectious disease has served to reduce wait times for patients and families to get into allergy specialty offices. This serves to enhance the patient's experience. Since the beginning of our project, we have encountered some data retrieval pitfalls and process failures which we are actively working with our quality groups on. It has become evident that widespread standardized protocols are needed. Our networking has provided opportunities and benefits to capture more patients. We have only encountered mild reactions to date. As of May 2023, we have been able to de-label approximately 17% of the patients in which a BPA has been fired.
SMART aim: Increase the % of patients with appropriate PCN allergy labels who present to ID clinic from 0 to 10% by December 2022.
Measure name: penicillin allergy de-labeling
Measure type (outcome, process, balancing): outcome measure
Type (individual, practice): group/practice
Measure: numerator/denominator: # patients with PCN allergy label who present to ID clinic successfully de- labeled/# of patients with PCN allergy identified patients in ID clinic
How are results presented (e.g., run chart): Percentage of total patients successfully de-labelled
QI methodology (improvement model/PDSA, LEAN, etc.): PDSA
Describe tests of change or interventions: Improve screening prior to appointment scheduling/create provider tip sheet/create order set/improve follow-up communication and tracking/provide a narrative summary of the project results/create a nursing triage in-basket for scheduling/QI/IT meetings to establish process mapping and failure modes with interventions and improve Epic data reporting/transition to nurse-driven project focus with help of ID pharm D/expand to include penicillin allergic inpatient challenges and follow-up. Following an internal review to improve detection of penicillin allergy label, we started working on increasing local expertise with the project through nursing grand rounds, our annual provider update.
The objectives of our project were: 1) Describe the allergy response and how it is used to stratify risks. 2) Identify the process in which the best practice advisory (BPA) is flagged in Epic and the subsequent plan of care. 3)
Recognize the health care impacts of de-labeling penicillin allergic patients.
The penicillin challenge is a safe, cost-effective, timely process to improve a public health issue directly impacting patient outcomes and health care costs globally. Participation of infectious disease has served to reduce wait times for patients and families to get into allergy specialty offices. This serves to enhance the patient's experience. Since the beginning of our project, we have encountered some data retrieval pitfalls and process failures which we are actively working with our quality groups on. It has become evident that widespread standardized protocols are needed. Our networking has provided opportunities and benefits to capture more patients. We have only encountered mild reactions to date. As of May 2023, we have been able to de-label approximately 17% of the patients in which a BPA has been fired.
SMART aim: Increase the % of patients with appropriate PCN allergy labels who present to ID clinic from 0 to 10% by December 2022.
Measure name: penicillin allergy de-labeling
Measure type (outcome, process, balancing): outcome measure
Type (individual, practice): group/practice
Measure: numerator/denominator: # patients with PCN allergy label who present to ID clinic successfully de- labeled/# of patients with PCN allergy identified patients in ID clinic
How are results presented (e.g., run chart): Percentage of total patients successfully de-labelled
QI methodology (improvement model/PDSA, LEAN, etc.): PDSA
Describe tests of change or interventions: Improve screening prior to appointment scheduling/create provider tip sheet/create order set/improve follow-up communication and tracking/provide a narrative summary of the project results/create a nursing triage in-basket for scheduling/QI/IT meetings to establish process mapping and failure modes with interventions and improve Epic data reporting/transition to nurse-driven project focus with help of ID pharm D/expand to include penicillin allergic inpatient challenges and follow-up. Following an internal review to improve detection of penicillin allergy label, we started working on increasing local expertise with the project through nursing grand rounds, our annual provider update.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/07/24
Purpose: This project aimed to provide a virtual, on-demand presence of a certified child life specialist (CCLS) and a pediatric clinical nurse specialist (CNS) to a rural health system in preparation for mass vaccination of children against SARS-CoV-2.
Description: Accidental punctures to patients during injections are often a result of inadequate comfort positioning of the pediatric patient. Comfort positions provide safety, support, and reassurance during stressful or painful procedures. Supine positioning increases distress for the child and decreases their desire to cooperate, while also increasing parent anxiety and decreasing satisfaction. Despite this, many nurses verbalize unfamiliarity with the practice of comfort positions and will resort to antiquated restraining techniques to limit the child’s movement during the procedure. As COVID-19 vaccines were authorized for children ages 5-11 years, a CCLS, pediatric CNS, and pediatric nurse education specialist collaborated to create education and resources to enhance the safety of pediatric patients during vaccination. Recognizing the many steps to a successful vaccination encounter, the team developed a video-on-demand education series that included assessment of the room; methods on how to approach a child, select, and engage a comfort position appropriate for the child’s age and development; and distraction tools, as well as prevention of post-vaccination fainting and falling in teens. A series was created to virtually demonstrate safe and successful comfort positioning options based on the child’s age. Learners were assigned to view the series and they were provided a post-test assessment of their learning.
Evaluation/outcome: The objectives for learners were: 1) describe how to assess the situation and manage room dynamics, 2) describe comfort positions that can be used for various age groups, 3) recognize when to intervene to provide correction and reinforcement of age-appropriate comfort positioning, 4) identify age-appropriate distraction tools, and 5) describe techniques to prevent fainting and falling in teens following vaccination. From November 2021 through November 2022, the post-test assessment was completed by 273 learners. The assessment revealed 94.8% of learners selected “agree” or “strongly agree” when asked if they achieved the learning objectives. 93% of learners agreed or strongly agreed that the format was effective to facilitate their learning. 92% of learners agreed or strongly agreed that the time to complete the activity was acceptable. The video series provided a successful learning activity and was far reaching. The series brought pediatric clinical experts into rural healthcare settings and expedited education in preparation for mass vaccination clinics. From November 2021 to date, the videos have been accessed outside of the assigned learning activity by nearly 500 unique viewers. Colleagues from inpatient pediatric settings have initiated a request to create a similar video series outlining procedures specific to their practice.
Description: Accidental punctures to patients during injections are often a result of inadequate comfort positioning of the pediatric patient. Comfort positions provide safety, support, and reassurance during stressful or painful procedures. Supine positioning increases distress for the child and decreases their desire to cooperate, while also increasing parent anxiety and decreasing satisfaction. Despite this, many nurses verbalize unfamiliarity with the practice of comfort positions and will resort to antiquated restraining techniques to limit the child’s movement during the procedure. As COVID-19 vaccines were authorized for children ages 5-11 years, a CCLS, pediatric CNS, and pediatric nurse education specialist collaborated to create education and resources to enhance the safety of pediatric patients during vaccination. Recognizing the many steps to a successful vaccination encounter, the team developed a video-on-demand education series that included assessment of the room; methods on how to approach a child, select, and engage a comfort position appropriate for the child’s age and development; and distraction tools, as well as prevention of post-vaccination fainting and falling in teens. A series was created to virtually demonstrate safe and successful comfort positioning options based on the child’s age. Learners were assigned to view the series and they were provided a post-test assessment of their learning.
Evaluation/outcome: The objectives for learners were: 1) describe how to assess the situation and manage room dynamics, 2) describe comfort positions that can be used for various age groups, 3) recognize when to intervene to provide correction and reinforcement of age-appropriate comfort positioning, 4) identify age-appropriate distraction tools, and 5) describe techniques to prevent fainting and falling in teens following vaccination. From November 2021 through November 2022, the post-test assessment was completed by 273 learners. The assessment revealed 94.8% of learners selected “agree” or “strongly agree” when asked if they achieved the learning objectives. 93% of learners agreed or strongly agreed that the format was effective to facilitate their learning. 92% of learners agreed or strongly agreed that the time to complete the activity was acceptable. The video series provided a successful learning activity and was far reaching. The series brought pediatric clinical experts into rural healthcare settings and expedited education in preparation for mass vaccination clinics. From November 2021 to date, the videos have been accessed outside of the assigned learning activity by nearly 500 unique viewers. Colleagues from inpatient pediatric settings have initiated a request to create a similar video series outlining procedures specific to their practice.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/07/24
Purpose: The purpose of this project was to implement social determinants screening to assess patient and family needs in an outpatient pediatric primary and specialty care setting.
Description: Health equity and anti-racism work are critical priorities for healthcare organizations, including this organization. As part of the organization’s focus on delivering on the health equity and anti-racism action plan, social determinants screening was approved by organizational leadership in May 2021 to better understand patient needs and barriers to care, with a goal of implementation within 6 months of project approval.
To prepare for the implementation into the ambulatory care primary and specialty clinics, a multidisciplinary team was formed with members from nursing and provider leadership, nursing informatics, health educators, social work, marketing and communication, registration staff, and electronic health care analysts. The project team identified unique challenges in a pediatric setting that required addressing prior to executing this important screening. These circumstances include addressing concerns for the child’s awareness of any hardships or insecurities a family may be experiencing, navigating shared access to the electronic medical record for legal guardians, and ensuring patient and caregiver safety for specific domain responses that may identifying an immediate safety concern. Four domains were selected for implementation, including transportation, food security, housing, and financial resources.
The patient population eligible for screening included all patients and families with appointments with their healthcare provider. Patient screening occurred through electronic tablets with the responses loading directly into the patient’s medical record for review by the healthcare team. Starting in November 2021, implementation across specialties and sites of care across 3 states occurred in a phased approach over the course of a year. No new resources were created for the first phase of the go-live and follow-up on patients indicating needing follow-up occurred via existing organizational resources and channels.
Evaluation/outcome: As of July 2023, over 1000 patients per month are requesting support for resources related to transportation, food security, housing, and financial resources. In response to clinician feedback, decision support tools were also developed and implemented over the phased implementation, including reports in the electronic medical record to ensure every patient received follow up who requested so. This resulted in an improvement from baseline of 31% compliance to documentation standards to nearly 80% compliance standards. We were also able to demonstrate improved screening scores in over 1000 patients with on subsequent social determinants screening. As a result of this screening and to better address the needs of the patients in the community, an additional FTE resource was identified and added to the team for SDOH follow-up.
Description: Health equity and anti-racism work are critical priorities for healthcare organizations, including this organization. As part of the organization’s focus on delivering on the health equity and anti-racism action plan, social determinants screening was approved by organizational leadership in May 2021 to better understand patient needs and barriers to care, with a goal of implementation within 6 months of project approval.
To prepare for the implementation into the ambulatory care primary and specialty clinics, a multidisciplinary team was formed with members from nursing and provider leadership, nursing informatics, health educators, social work, marketing and communication, registration staff, and electronic health care analysts. The project team identified unique challenges in a pediatric setting that required addressing prior to executing this important screening. These circumstances include addressing concerns for the child’s awareness of any hardships or insecurities a family may be experiencing, navigating shared access to the electronic medical record for legal guardians, and ensuring patient and caregiver safety for specific domain responses that may identifying an immediate safety concern. Four domains were selected for implementation, including transportation, food security, housing, and financial resources.
The patient population eligible for screening included all patients and families with appointments with their healthcare provider. Patient screening occurred through electronic tablets with the responses loading directly into the patient’s medical record for review by the healthcare team. Starting in November 2021, implementation across specialties and sites of care across 3 states occurred in a phased approach over the course of a year. No new resources were created for the first phase of the go-live and follow-up on patients indicating needing follow-up occurred via existing organizational resources and channels.
Evaluation/outcome: As of July 2023, over 1000 patients per month are requesting support for resources related to transportation, food security, housing, and financial resources. In response to clinician feedback, decision support tools were also developed and implemented over the phased implementation, including reports in the electronic medical record to ensure every patient received follow up who requested so. This resulted in an improvement from baseline of 31% compliance to documentation standards to nearly 80% compliance standards. We were also able to demonstrate improved screening scores in over 1000 patients with on subsequent social determinants screening. As a result of this screening and to better address the needs of the patients in the community, an additional FTE resource was identified and added to the team for SDOH follow-up.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Kaitlyn Gore, MSN, RN, CCRN | Calli Wood, MSN Ed, RN, NPD-BC, Director of Ambulatory Nursing Education and Training, UT Southwestern Medical Center
Updated: 03/07/24
Learning outcome: After viewing this presentation, the learner will be able to describe the importance of ambulatory care clinical ladders in professional development and how to operationalize a health system clinical ladder.
Purpose: Clinical ladders are proven to have a positive impact on nurse retention, engagement, and certification rates, and they are strongly correlated with an intent to stay. At one large academic medical center, two separate and distinct clinical ladders existed between inpatient and ambulatory care nursing teams. Each ladder had its strengths and weaknesses, and as such, there were some subtle differences between the two programs. Differences included pay practice inequities, rigor imbalance, and uneven availability of options to participants. The two programs were created separately and on different timelines, each growing to be successful over the years. In 2016, a chief nursing executive position was created, thus bringing all of nursing under one leader and initiating a unified health system mindset. Through feedback from existing ladder participants and leaders, a need was identified by the office of nursing excellence to make one unified, system-wide program for the nurse clinical ladder.
Description: In September 2022, a workgroup was launched and spearheaded by the ambulatory care director of nursing professional development. The group comprised inpatient and ambulatory care leaders, nursing excellence, research, direct care staff, NPD practitioners, and nursing executive leadership. The workgroup analyzed program guidelines of other healthcare facility clinical ladders as a basis for best practice. When inspecting these programs for best practices, special considerations were made regarding pay practices and their relation to rigor. Similar options in the ambulatory and inpatient care programs were cross-walked, then adopted or eliminated. The options were combined and weighted according to the effort of the work performed. Weighing options was a new concept for both ladders, which brought respect to work that required more time and rigor than other options. This concept also allows for executives to leverage certain options in the ladder to move the needle on organizational goals, if necessary. With such a large impact initiative that involved staff financials, it was imperative to author a comprehensive communication plan in advance of the go-live. Over the span of six months, details on the new ladder were disseminated across all shared governance councils, staff and leader town halls were provided, and multiple open office hours were offered.
Evaluation/outcome: The unified Health system nurse clinical ladder had its inaugural cohort of packets submitted in September 2023. This was a limited pilot group of 15 successful participants. The newly formed health system clinical ladder committee, comprised of inpatient and ambulatory care advisors, performed their commencing joint packet review day. This streamlined grading process ensures an unbiased, efficient system for determining outcome of level achieved and has shown to increase collaboration between inpatient and ambulatory care team members. Current letter of intent (LOI) submissions for newly biannual packet submissions have exceeded FY23 numbers (142), totaling 175 LOIs FY to date. About another 100 LOIs are still anticipated for the second packet submission window in August 2024.
Purpose: Clinical ladders are proven to have a positive impact on nurse retention, engagement, and certification rates, and they are strongly correlated with an intent to stay. At one large academic medical center, two separate and distinct clinical ladders existed between inpatient and ambulatory care nursing teams. Each ladder had its strengths and weaknesses, and as such, there were some subtle differences between the two programs. Differences included pay practice inequities, rigor imbalance, and uneven availability of options to participants. The two programs were created separately and on different timelines, each growing to be successful over the years. In 2016, a chief nursing executive position was created, thus bringing all of nursing under one leader and initiating a unified health system mindset. Through feedback from existing ladder participants and leaders, a need was identified by the office of nursing excellence to make one unified, system-wide program for the nurse clinical ladder.
Description: In September 2022, a workgroup was launched and spearheaded by the ambulatory care director of nursing professional development. The group comprised inpatient and ambulatory care leaders, nursing excellence, research, direct care staff, NPD practitioners, and nursing executive leadership. The workgroup analyzed program guidelines of other healthcare facility clinical ladders as a basis for best practice. When inspecting these programs for best practices, special considerations were made regarding pay practices and their relation to rigor. Similar options in the ambulatory and inpatient care programs were cross-walked, then adopted or eliminated. The options were combined and weighted according to the effort of the work performed. Weighing options was a new concept for both ladders, which brought respect to work that required more time and rigor than other options. This concept also allows for executives to leverage certain options in the ladder to move the needle on organizational goals, if necessary. With such a large impact initiative that involved staff financials, it was imperative to author a comprehensive communication plan in advance of the go-live. Over the span of six months, details on the new ladder were disseminated across all shared governance councils, staff and leader town halls were provided, and multiple open office hours were offered.
Evaluation/outcome: The unified Health system nurse clinical ladder had its inaugural cohort of packets submitted in September 2023. This was a limited pilot group of 15 successful participants. The newly formed health system clinical ladder committee, comprised of inpatient and ambulatory care advisors, performed their commencing joint packet review day. This streamlined grading process ensures an unbiased, efficient system for determining outcome of level achieved and has shown to increase collaboration between inpatient and ambulatory care team members. Current letter of intent (LOI) submissions for newly biannual packet submissions have exceeded FY23 numbers (142), totaling 175 LOIs FY to date. About another 100 LOIs are still anticipated for the second packet submission window in August 2024.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/07/24
Learning outcome: Poster presentation learners will identify innovative strategies to address the ambulatory care nursing shortage.
Purpose: Over the last two decades, visits to ambulatory care facilities have steadily increased. As a result, there is a need to increase the ambulatory care workforce, including registered nurses (RNs). Experienced RNs have long been the preferred choice for hiring in the ambulatory care clinical setting. Given the nurse shortage exacerbated by the COVID-19 pandemic, ambulatory care leaders recognized the need to increase the proportion of new gradate registered nurses (NGRN). The purpose of the project was to create an innovative and effective transition-to-practice (TTP) program for NGRN and nurses transitioning from other specialties called transition fellows (TF).
Description: To facilitate an effective TTP program, nursing professional development specialists (NPDs) at a large urban pediatric hospital, developed a one-year ambulatory care specialty TTP program to address the immediate need for RNs. This program entailed a 9-week immersion period that included ambulatory care-specific didactics, preceptorship, shadowing opportunities with interdisciplinary team members, and debriefing sessions. Literature review also provided well-supported evidence that academic partnerships enhance ambulatory care training. Therefore, the NPDs leadership team advocated for the participation in a state-wide comprehensive ambulatory care-specialty RN apprenticeship program. This collaboration provided a well-rounded combination of instructor-led and asynchronous course work. Specific skills emphasized for ambulatory care NGRNs included care coordination, telephone triage, and leadership. Additionally, clinic-specific competency development aided in enhancing each NGRN's clinical practice over the one-year program. Interactive activities such as simulation and roleplay were incorporated in clinical skill stations focused on outpatient medical emergencies, de-escalation, and crisis prevention scenarios.
Evaluation/outcome: The initial two NGRNs have completed the inaugural program and one TF successfully transitioned to ambulatory care nursing. Currently, one NGRN is enrolled in the second cohort. Retention 18 months after program completion is 100%. Clinic-specific didactic class evaluations indicated that topics presented were relevant to practice. The participants demonstrated improvement in their critical-thinking by navigating from being task-oriented to performing autonomously in a fast-paced ambulatory care setting. Participation in an evidence-based practice (EBP) project promoted teamwork, ambulatory care needs assessment, and process change recommendations. The new TTP program enhances manager and preceptor collaboration in creating a successful learning environment, in addition to establishing collaborative partnerships. Through strategic planning, NPDs paved the way for a program that prepares ambulatory care nurses to provide high-quality care to specialized pediatric patient population.
Purpose: Over the last two decades, visits to ambulatory care facilities have steadily increased. As a result, there is a need to increase the ambulatory care workforce, including registered nurses (RNs). Experienced RNs have long been the preferred choice for hiring in the ambulatory care clinical setting. Given the nurse shortage exacerbated by the COVID-19 pandemic, ambulatory care leaders recognized the need to increase the proportion of new gradate registered nurses (NGRN). The purpose of the project was to create an innovative and effective transition-to-practice (TTP) program for NGRN and nurses transitioning from other specialties called transition fellows (TF).
Description: To facilitate an effective TTP program, nursing professional development specialists (NPDs) at a large urban pediatric hospital, developed a one-year ambulatory care specialty TTP program to address the immediate need for RNs. This program entailed a 9-week immersion period that included ambulatory care-specific didactics, preceptorship, shadowing opportunities with interdisciplinary team members, and debriefing sessions. Literature review also provided well-supported evidence that academic partnerships enhance ambulatory care training. Therefore, the NPDs leadership team advocated for the participation in a state-wide comprehensive ambulatory care-specialty RN apprenticeship program. This collaboration provided a well-rounded combination of instructor-led and asynchronous course work. Specific skills emphasized for ambulatory care NGRNs included care coordination, telephone triage, and leadership. Additionally, clinic-specific competency development aided in enhancing each NGRN's clinical practice over the one-year program. Interactive activities such as simulation and roleplay were incorporated in clinical skill stations focused on outpatient medical emergencies, de-escalation, and crisis prevention scenarios.
Evaluation/outcome: The initial two NGRNs have completed the inaugural program and one TF successfully transitioned to ambulatory care nursing. Currently, one NGRN is enrolled in the second cohort. Retention 18 months after program completion is 100%. Clinic-specific didactic class evaluations indicated that topics presented were relevant to practice. The participants demonstrated improvement in their critical-thinking by navigating from being task-oriented to performing autonomously in a fast-paced ambulatory care setting. Participation in an evidence-based practice (EBP) project promoted teamwork, ambulatory care needs assessment, and process change recommendations. The new TTP program enhances manager and preceptor collaboration in creating a successful learning environment, in addition to establishing collaborative partnerships. Through strategic planning, NPDs paved the way for a program that prepares ambulatory care nurses to provide high-quality care to specialized pediatric patient population.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/07/24
Purpose: To attract and retain licensed vocational nurses (LVNs), the principal nursing force in ambulatory care, by establishing a transition to practice program in the ambulatory care setting.
Description: In a major metropolitan city with many LVN programs, no documented residency programs were advertised to attract graduating LVNs. Our institutional data showed that from November 2020 to October 2021, approximately 56 LVNs were hired, with about 63 LVN vacancies remaining. An LVN residency program was implemented in April 2022 comprised of 18 newly graduated LVNs or those with less than one year of experience. Addressing the LVN graduate nurse practice gaps and risk for practice errors can lead to job satisfaction and retention.
Planning included collaborations with nursing schools, communities of practice including LVNs, outside healthcare organizations, and six interprofessional in-house departments. Barriers included awareness of the program from our internal and external customers, participants not finishing the residency due to enrolling in registered nursing programs, and buy-in that a LVN residency was needed in a large medical center.
Implementation of the plan involved six conference sessions of in-person instruction, self-paced modules, simulations, clinical practice, and reflective learning assignments. Weekly meetings were done with the nurse manager, preceptor, and educator to evaluate progress. The impact, which is still ongoing, is to produce LVNs confident with role expectations, competent in clinical role requirements, and fill vacancies.
The goals for this program include retaining LVNs in ambulatory care; demonstrating knowledge, skills, and attitudes reflecting safe quality patient care; and providing a seamless practice transition from school to clinic. Our staffing outcome was to retain 75% of the initial cohort after six months and 50% after one year. Many of our LVN new hires are new graduates.
Program learning outcome: Participants will illustrate safe nursing practice within their scope of practice in the ambulatory care environment, demonstrated by proper knowledge, skills, and attitudes related to safe quality patient care in the areas of patient/family-centered care, communication, teamwork, quality, EBP, and informatics.
Overall evaluation/outcome: Weekly meetings were done with the nurse manager, preceptor, and educator to evaluate the LVN’s progress using a competence-based clinical orientation tool and weekly progress reports, which assess knowledge, skills, and attitudes exhibiting safe quality patient care. The ongoing impact results convey confidence with role expectations, competence in clinical role requirements, and filled vacancies versus using overtime dollars. The staffing outcome for six months and one year was met.
Description: In a major metropolitan city with many LVN programs, no documented residency programs were advertised to attract graduating LVNs. Our institutional data showed that from November 2020 to October 2021, approximately 56 LVNs were hired, with about 63 LVN vacancies remaining. An LVN residency program was implemented in April 2022 comprised of 18 newly graduated LVNs or those with less than one year of experience. Addressing the LVN graduate nurse practice gaps and risk for practice errors can lead to job satisfaction and retention.
Planning included collaborations with nursing schools, communities of practice including LVNs, outside healthcare organizations, and six interprofessional in-house departments. Barriers included awareness of the program from our internal and external customers, participants not finishing the residency due to enrolling in registered nursing programs, and buy-in that a LVN residency was needed in a large medical center.
Implementation of the plan involved six conference sessions of in-person instruction, self-paced modules, simulations, clinical practice, and reflective learning assignments. Weekly meetings were done with the nurse manager, preceptor, and educator to evaluate progress. The impact, which is still ongoing, is to produce LVNs confident with role expectations, competent in clinical role requirements, and fill vacancies.
The goals for this program include retaining LVNs in ambulatory care; demonstrating knowledge, skills, and attitudes reflecting safe quality patient care; and providing a seamless practice transition from school to clinic. Our staffing outcome was to retain 75% of the initial cohort after six months and 50% after one year. Many of our LVN new hires are new graduates.
Program learning outcome: Participants will illustrate safe nursing practice within their scope of practice in the ambulatory care environment, demonstrated by proper knowledge, skills, and attitudes related to safe quality patient care in the areas of patient/family-centered care, communication, teamwork, quality, EBP, and informatics.
Overall evaluation/outcome: Weekly meetings were done with the nurse manager, preceptor, and educator to evaluate the LVN’s progress using a competence-based clinical orientation tool and weekly progress reports, which assess knowledge, skills, and attitudes exhibiting safe quality patient care. The ongoing impact results convey confidence with role expectations, competence in clinical role requirements, and filled vacancies versus using overtime dollars. The staffing outcome for six months and one year was met.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Ricardo Ballin, DNP, RN, CNML | Lillian J. Jones-Bell, MSN Ed, RN, PHN, Education Consultant, California Health Impact State Nursing Workforce
Updated: 03/07/24
Learning outcome: The learner will identify steps taken in the process of developing a statewide transition to practice ambulatory care nurse apprenticeship program.
Purpose: The purpose was to create a statewide ambulatory care nursing apprenticeship program in under-resourced organizations. Experts in ambulatory care nursing and teaching/learning methods implemented the program, which traversed a large geographic region. Particular foci of the program included ambulatory care specific topics, well-being support for ambulatory care nurse apprentices, and development of skill acquisition. One priority for this program was to allow multiple employers who needed expertise in ambulatory care and apprenticeship programs to participate and support new nurses to the ambulatory care specialty.
Description: Utilizing a synchronous Hyflex virtual learning environment, the program partnered with organizations seeking support for nurses new to ambulatory care. Partnering with regional workforce development boards and hospital trade associations located in underserved communities in Southern California, the first registered nurse ambulatory specialty apprenticeship program was implemented. One of the key goals of the program was to address retention and professional growth of the apprentice nurses transitioning into ambulatory care professional practice. The 12-month program included 240 hours of instruction and 1700+ hours of on-the-job training. The curriculum framework was created utilizing the American Academy of Ambulatory Care Nursing (AAACN) competencies and standards. The program provided a psychologically safe environment that supported the nurse apprentices with the myriad of morally stressful situations encountered in the ambulatory care environment.
Evaluation/outcomes: From the initial to the final self-evaluation, every apprentice met all competency standards as established by the AAACN Scope and Standards for program completion. The significant morally distressing situations encountered by the apprentices were mitigated utilizing a reflective journaling pedagogy and psychologically safe discussions. The nurse retention rate in the program was 89%, which included two nurses who were promoted while in the program within their hiring organization. The benefits to under-resourced organizations were being able to provide a no-cost apprenticeship program, investment in the organization through the apprentices’ quality and process improvement projects, and a high retention rate at the end of the program. Program outcomes included ongoing financial support for the apprenticeship program to expand to other regions of the state with the ability to accept the next cohort of nurses from returning partners as well as new ambulatory care organizations. In addition, providing a statewide apprenticeship program in ambulatory care nursing supports the health and well-being of the state’s population.
Purpose: The purpose was to create a statewide ambulatory care nursing apprenticeship program in under-resourced organizations. Experts in ambulatory care nursing and teaching/learning methods implemented the program, which traversed a large geographic region. Particular foci of the program included ambulatory care specific topics, well-being support for ambulatory care nurse apprentices, and development of skill acquisition. One priority for this program was to allow multiple employers who needed expertise in ambulatory care and apprenticeship programs to participate and support new nurses to the ambulatory care specialty.
Description: Utilizing a synchronous Hyflex virtual learning environment, the program partnered with organizations seeking support for nurses new to ambulatory care. Partnering with regional workforce development boards and hospital trade associations located in underserved communities in Southern California, the first registered nurse ambulatory specialty apprenticeship program was implemented. One of the key goals of the program was to address retention and professional growth of the apprentice nurses transitioning into ambulatory care professional practice. The 12-month program included 240 hours of instruction and 1700+ hours of on-the-job training. The curriculum framework was created utilizing the American Academy of Ambulatory Care Nursing (AAACN) competencies and standards. The program provided a psychologically safe environment that supported the nurse apprentices with the myriad of morally stressful situations encountered in the ambulatory care environment.
Evaluation/outcomes: From the initial to the final self-evaluation, every apprentice met all competency standards as established by the AAACN Scope and Standards for program completion. The significant morally distressing situations encountered by the apprentices were mitigated utilizing a reflective journaling pedagogy and psychologically safe discussions. The nurse retention rate in the program was 89%, which included two nurses who were promoted while in the program within their hiring organization. The benefits to under-resourced organizations were being able to provide a no-cost apprenticeship program, investment in the organization through the apprentices’ quality and process improvement projects, and a high retention rate at the end of the program. Program outcomes included ongoing financial support for the apprenticeship program to expand to other regions of the state with the ability to accept the next cohort of nurses from returning partners as well as new ambulatory care organizations. In addition, providing a statewide apprenticeship program in ambulatory care nursing supports the health and well-being of the state’s population.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
