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Nurse Leaders Study Value of Ambulatory Care Nurses

Monday February 12, 2007
<B>Regina Conway-Phillips, RN, MSN</B>
Regina Conway-Phillips, RN, MSN
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Sometimes nurses who work in doctors' offices, clinics, and other ambulatory care settings feel they aren't valued as highly as their acute care counterparts.

"There appears to be this stigma in regard to ambulatory care nursing," says Regina Conway-Phillips, RN, MSN, immediate past president of the American Academy of Ambulatory Care Nursing (AAACN). "[Nurses who] went to [work at] an ambulatory care clinic aren't seen in the same light as a nurse, for example, who works in the ICU or on the floors.

"One of the things I had observed in my practice," says Conway-Phillips, a manager at Humana, Inc., in Chicago, "is typically when it's budget time or there's a crisis and the decision makers are trying to cut costs, RNs are seen as a high-cost resource."

The desire to help nurses, employers, and third-party payers recognize and value ambulatory care nursing led the AAACN to survey its members about their perceived value. That, in turn, led Conway-Phillips and others to conduct a literature search on the economic value of ambulatory care RNs in hopes that their findings would help others recognize their value. The results of that literature search appear in the November/December 2006 issue of Nursing Economic$.

Fewer RNs = lower quality of care

"Demonstrating the Value of the RN in Ambulatory Care" is co-authored by Conway-Phillips; Beth Ann Swan, PhD, CRNP, FAAN, associate dean for graduate nursing programs at Thomas Jefferson University in Philadelphia; and Karen F. Griffin, RN, MSN, CNAA, associate chief nurse for ambulatory care at the South Texas Veterans Healthcare System.

"Some organizations were actually decreasing the number of RNs in the clinics, and it was affecting the quality of care," says Griffin. So Griffin, Conway-Phillips, and Swan set out to find literature that describes the quality of these RNs and "maybe even puts a number to the value of RNs," Griffin continues.

The literature search turned out to be harder than anyone imagined.

"There's not much in the literature on the value of the RN in ambulatory care," says Swan. "I engaged a search librarian to help me with the search because I wasn't coming up with much, and even she remarked that she was surprised at the sparseness of literature on this topic."

Their search turned up 21 articles of studies that demonstrate the value of RNs who work in ambulatory care. The values demonstrated include —

• Increased patient satisfaction related to continuity of care and communications with providers

• Improved patient self-efficacy, self-care, quality of life, and physiological markers such as blood pressure and hemoglobin A1c

• Fewer hospital visits, hospital re-admissions, and emergency room visits

• Improved operational efficiency

• Improved management of service demands

• Reduced cost and/or cost savings

Placing a dollar figure on the value of ambulatory care turned out to be more difficult. Only three of the articles included information on specific savings attributed to nurses who work in ambulatory care settings.

One study found that an RN-managed program for patients living with HIV/AIDS resulted in a savings of $1.6 million in 1993 by reducing hospitalizations and emergency room visits, shortening hospital stays, and providing 25% of complex medical treatments.

"The idea is with RN care you can manage the patient successfully in a lower-cost setting of care," Swan says. "It's better for me to be seen in the ambulatory care setting rather than need an acute care hospitalization."

In another study, nurses provided prenatal support by telephone to high-risk pregnant women, reducing the number of pre-term and low-birth-weight infants. The savings in medical costs amounted to $277 per participant. Yet another study at an RN-managed ear clinic in Great Britain resulted in a cost savings of $88,000 for 626 patients.

One thing Swan hopes their findings will do is inform people about the number of RNs who are practicing in ambulatory care, the variety of settings in which they practice, and the impact they have.

"They ultimately do save healthcare organizations money or actually make healthcare organizations money because patients continue to return to that place for their care," Swan says.

Most of the cost savings is attributed to preventing illnesses or complications.

"They have found that it is cheaper to keep patients healthy than it is to treat them once they have a disease process going on," Griffin says. "There has been a big turnaround in the last 10 years at looking at prevention and what we can do to keep people healthy."

"I would like to see organizations that currently have indicators in place for acute care nurses have those same indicators in place for ambulatory care nurses," says Conway-Phillips. "With an increased amount of health care taking place in the ambulatory care setting, there needs to be an urgency in getting this information out there."

The U.S. Department of Health and Human Services estimates that 29% of U.S. nurses work in an ambulatory care setting, compared with 24% in 2000. That's because of to the shift toward the delivery of health care to ambulatory settings whenever possible, especially among the elderly.

The value of ambulatory care nursing can't — and shouldn't — always be thought of in monetary terms, Griffin says. Value also can be found in keeping people healthy, avoiding hospitalizations, and helping the elderly to remain in their homes as long as possible. This will become even more important as baby boomers reach old age.

"We have to start now so when we get there, there are systems in place to take care of that large population," she says.

Newly licensed nurses tend to look to acute care settings for their first jobs, Swan says, and she thinks one reason is the education and training they receive in college.

"I think some of it has to do with their indoctrination in nursing school of a heavily-focused curriculum on acute care," she says. "There's more care being delivered in the ambulatory care setting overall, and, from the data I was able to find in the search, the projections are that there will be more care given in the ambulatory care setting and there will be a need for more RNs to be practicing in that setting as well."

Griffin hopes their work will help with recruiting nurses into ambulatory care.

Conway-Phillips says she plans to continue working to demonstrate the value of ambulatory care nursing. She currently is working toward completing a PhD from Loyola University Chicago and plans to write her dissertation on identifying the value of registered nursing in the ambulatory care setting. She describes herself as passionate about the role ambulatory care nurses play, and she wants others to appreciate their value, too.

"I would like to see it articulated," she says. "I would like to see it supported with research and quantified. Also, I would like to see research that can quantify and validate what ambulatory care nurses intuitively know about what they bring to their role in ambulatory care."

Scott Williams is a freelance writer.

To comment on this story, e-mail jboivin@gannetthg.com.