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Ambulatory care roles expected to continue rapid growth

Monday February 11, 2013
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Suzanne Wells, RN
With an emphasis on shorter hospital stays and technological advances, nurses are finding a wealth of unique opportunities in ambulatory care.As the need for nurses grows, so does a wide variety of specialties that local nurses find particularly rewarding, including the following:

Periperative nursing

The number of outpatient surgeries tripled in the decade between 1996 and 2006, according to the Centers for Disease Control and Prevention, and now make up about two-thirds of all surgeries.

Changes in insurance payments and advances in technology now mean many bowel resections, cataract surgeries, mastectomies, appendectomies and gallbladder removals can be done in ambulatory settings, opening up roles for nurses.

"That’s the place to be now — ambulatory surgery," said Theresa Criscitelli, RN, MS, CNOR, director of perioperative education at Winthrop-University Hospital in Mineola, N.Y.

This is a great specialty for nurses who love a fast-paced environment and technology, she said. Many procedures are performed laparoscopically or endoscopically. The nurse also educates patients and families throughout the day.

Adrienne DeRosa, NP
"(Patients are) awake, they’re a little bit healthier … and they want to learn," Criscitelli said.

Annie Pena, RN, MSHA, MBA, also works with patients undergoing surgery in an ambulatory setting. All surgeries in the ambulatory surgical pavilion of Robert Wood Johnson University Hospital in New Brunswick, N.J., are elective, she said, and the pace is quick. Pena said nurses need to come with operating room skill sets in place.

Her center completes about six surgeries a day, whereas a traditional hospital OR may see three a day, Pena said.

Ambulatory surgery centers are popular, she said, partly because patients don’t have to go through a series of departments.

"Here, it’s one floor, and you’re in and out," Pena said.

They also have a very low rate of infections, she said, because the patients are generally well and not coming in with viruses or diseases.


Nurses are key players in slowing the rapid rise of diabetes, which affects 8% of the population, according to the CDC, and is expected to affect as many as one of three U.S. adults by 2050.

Mary Rieff, RN
Demand has grown for nurses who can educate patients on lifestyle changes to help prevent the disease and to help patients with diabetes navigate technological and other options to manage it. Some glucometers now connect to a patient’s smartphone or tablet computer, for instance, and nurses can show patients how to use the equipment and interpret the data.

Nurses interested in diabetes education and management roles should consider sitting for the certified diabetes educator exam, said Mary Rieff, RN, CDE, Stony Brook Diabetes Center in East Setauket, N.Y.

Hospitals, diabetes centers and endocrinologists are among those looking for certified diabetes educators, Rieff said.

LEARN MORE about requirements for CDE certification at NCBDE.org/Certification_Info/What-is-a-CDE.

Wound care

Among Lucy Hernandez’s responsibilities as patient service manager and manager for ambulatory care at Calvary Hospital in the Bronx is treating patients in Calvary’s Center for Curative & Palliative Wound Care.

Annie Pena, RN
The aging patient population, and particularly the growth in numbers of patients with diabetes, has boosted demand for wound care specialists. Certain wounds, such as foot ulcers, are more common among diabetics. Hernandez, APRN, NP-BC, said she, two other nurses and two paraprofessionals treat up to 50 patients a day who have chronic wounds.

Pain management and education also are a significant part of the job. Nurses help patients manage multiple medications and coordinate care plans with the patient’s primary care physician. Job satisfaction, according to Hernandez, comes from working with the same patients over a long period of time who are going to get better. "They become like family," she said.

Wound care can lead to saving a limb or enabling a patient to walk again. Achieving Wound, Ostomy and Continence Nursing certification will help nurses interested in this field land jobs with opportunities to work more autonomously, Hernandez said.

FOR INFORMATION about WOCN certification, visit WOCN.org.

Psychiatric nursing

Psychiatric nurses at the Jersey City (N.J.) Medical Center Ambulatory Care Center’s day program help patients transition from institutions or hospitals to live and work or go to school in the community.

Though their focus is mental health, nurses also must recognize physical issues, said Blythe Johnson, RN, BSN, and that takes building a rapport with the patients. A patient with schizophrenia who has paranoia issues, for instance, may hide a wound or may not want nurses to know about other illnesses, she said. Many patients have multiple diagnoses, so nurses have to be skilled in many areas and quick to adapt, Johnson said.

"As well as having a diagnosed mental illness, they may also have issues with addiction and substance abuse," she said. Nurses need to coordinate care and educate the patient on taking multiple medications and how to manage their diagnoses.

"Our whole purpose is to keep them stable," Johnson said.

Rewards from this work come in knowing that many patients are estranged from their families and a nurse may be their only link to healthcare, Johnson said. A nurse’s intervention may be what keeps them out of a shelter, inpatient care or an institution.

Comprehensive congestive heart failure

The heart failure clinic at Maimonides Medical Center in Brooklyn is run by nurse practitioners with a collaborating physician.

The NPs assess and refer underserved patients who don’t have a primary care or cardiology physician, said Adrienne DeRosa, NP. "We manage their heart failure" and help them to stay in their current stage of the disease, rather than rapidly progressing to end-stage, she said. A decade ago, patients with heart failure had a high recidivism rate and higher death rate because there were fewer surgical and therapy options, she said.

Now, NPs help patients navigate options such as coronary artery revascularization procedures, implantation of defibrillators and biventricular pacemakers. They analyze medication profiles and follow patients from acute care to their homes and assess them when they return to the clinic for visits. "I find that putting advanced practice nurses into these positions gives them a sense of creativity, a sense of autonomy," DeRosa said. "The patients are their patients."

Marcia Frellick is a freelance writer.

To comment, email editorNY@nurse.com.
Ambulatory roles on rise

Several developments in recent years have greatly increased the opportunities for nurses in ambulatory or outpatient care.
Today, ambulatory settings employ 25% of RNs in the U.S., nearly double the percentage they employed in 2008, according to the U.S. Department of Health and Human Services. The previous ambulatory model of single physicians in private practices has given way to a coordinated team approach that depends heavily on nurse practitioners, staff nurses, nurse researchers and consultants.
One of the primary drivers is the Affordable Care Act, said Suzanne Wells, RN, MSN, president of the American Academy of Ambulatory Care Nursing.
“As we know now, the ACOs (accountable care organizations) and medical homes are bringing care to the primary care setting, so we’re seeing more in the outpatient or ambulatory areas,” she said.
Advances in technology and telemedicine also make it possible for more procedures to happen outside a hospital, opening more opportunities for nurses.
A younger generation of technology-savvy patients also demands health information immediately, fueling the need for call centers that answer questions, make referrals and reach out to patients for physicians’ offices.
The sheer numbers of patients needing management of chronic illnesses also has increased the need for nurses.
“The role of the registered nurse is critical because we have the capability, the skills, the education and training to direct care and oversee other staff members,” Wells said.

— By Marcia Frellick, freelance writer