MMajor technological advances over thepast 10 years have changed the way patientcare is delivered in health care settings. Formany years, due to the complexity of thetesting and the large, expensive equipmentthat was required to analyze specimens, allor a majority of laboratory testing was per-formed in a central off-site laboratory.Computer chip technology has allowed test-ing to be performed with small, portable,and in many cases, hand-held machineswhich have revolutionized both the timeli-ness of results and the ability to modify theplan of care during a patient encounter. Thismode of testing is known as point of caretesting (POCT).

POCT refers to testing that is done nearthe patient. POCT may be conducted inmany locations including physician offices, atthe bedside, in a pharmacy, or in a patient’shome.

In an interview with Medscape.com,Frederick L. Kiechle, MD, PhD, suggests thatPOCT evolved in three phases. The first

The Official Publication of the American Academy of Ambulatory Care Nursing

Volume 30 Number 6

phase and earliest applications of POCT(1970-1988) comprised tests that could beeasily performed by a nurse, technician, orphysician. These tests included fecal occultblood, gastric occult blood, and dipstick uri-nalysis. There was little to no regulationregarding the performance and results ofthese tests. Formal education and compe-tency assessment standards for testers didnot exist.

Testing advanced into the second phasein the late 1980’s when the AmericanDiabetes Association revised its guidelines forglucose testing. Whole blood glucose testingvia finger stick replaced urine glucose test-ing. Patients were taught to monitor theirblood glucose levels and administer insulinfollowing a sliding scale, which greatlyimproved the patient’s ability to self-manageglucose control.

Despite these improvements, severalyears passed before bedside glucose fingersticks replaced serum glucose testing by cen-tral hospital laboratories. This lag between

continued on page 8March 26-30, 2009

See page 16

NOVEMBER/DECEMBER 2008

InsideFEATURESPage 3Pandemic Influenza: AStakeholder MeetingAAACN members attended the CDCCall Centers Coordination forPandemic Influenza StakeholderMeeting. Attendees brainstormed tocreate a workbook for coordinatingand utilizing call centers during apandemic influenza.

Page 4Defining the Role of theProfessional Nurse in theAmbulatory Care SettingWhat are the differences in the rolesof RNs, LPNs/LVNs, and MAs in anambulatory care setting? This topicwas posed via a question onAAACN's Web site. See questions andthe responses from our Expert Panel.

AAACN NEWSPage 6• Scholarship/Awards

Application Deadline• New Electronic Renewal

Notices

Page 10Our Voice CountsLearn what the new LegislativeCommittee is doing to promoteadvocacy and inform members aboutthe legislative process.

Eileen M. Esposito

2 V I EWPO I NT NOV E M B E R/ DEC E M B E R 2008

From thePRESIDENT

Real Nurses. Real Issues. Real Solutions.

American Academy ofAmbulatory Care Nursing

Reader ServicesAAACN ViewpointThe American Academy of AmbulatoryCare NursingEast Holly Avenue Box 56Pitman, NJ 08071-0056(800) AMB-NURSFax (856) 589-7463E-mail: aaacn@ajj.comWeb site: www.aaacn.org

AAACN Viewpoint is owned and publishedbimonthly by the American Academy ofAmbulatory Care Nursing (AAACN). Thenewsletter is distributed to members as adirect benefit of membership. Postage paid atBellmawr, NJ, and additional mailing offices.

AdvertisingContact Tom Greene, AdvertisingRepresentative, (856) 256-2367.

Back IssuesTo order, call (800) AMB-NURS or(856) 256-2350.

Editorial ContentAAACN encourages the submission of newsitems and photos of interest to AAACN mem-bers. By virtue of your submission, you agreeto the usage and editing of your submissionfor possible publication in AAACN's newslet-ter, Web site, and other promotional and edu-cational materials.

To send comments, questions, or article sug-gestions, or if you would like to write for us,contact Editor Rebecca Linn Pyle atbeckypyle@msn.com

AAACN Publications andProductsTo order, visit our Web site: www.aaacn.org.

ReprintsFor permission to reprint an article, call(800) AMB-NURS or (856) 256-2350.

SubscriptionsWe offer institutional subscriptions only. Thecost per year is $80 U.S., $100 outside U.S.To subscribe, call (800) AMB-NURS or (856)256-2350.

IndexingAAACN Viewpoint is indexed in theCumulative Index to Nursing and AlliedHealth Literature (CINAHL).

© Copyright 2008 by AAACN. All rightsreserved. Reproduction in whole or part, elec-tronic or mechanical without written permissionof the publisher is prohibited. The opinionsexpressed in AAACN Viewpoint are those of thecontributors, authors and/or advertisers, and donot necessarily reflect the views of AAACN,AAACN Viewpoint, or its editorial staff.

Publication Management by Anthony J. Jannetti, Inc.

IBuild Your Leadership Skills

By VolunteeringIn my previous message I discussed the qualities of

a leader and how every ambulatory care nurse is aleader no matter what their role. We all play a vital partin making our workplace and AAACN a remarkableorganization. Now I would like to discuss the impor-tance of participation and volunteerism in buildingleadership skills and advancing nursing practice.

Professional associations depend on interested,dedicated, and committed members to support thevarious activities of the association. These activitiesshow visible participation in the community of nurs-ing and support the positive image of nursing.

Volunteer work and participation can provide a welcome change tothe day-to-day activities at work and at home. By volunteering, you canexperience new perspectives and develop new skills. By participating incommittees and other task groups, your voice can be heard and positivechanges can be made. When you volunteer, you have the opportunity tolisten, to observe, and to use often scarce resources to tackle problems ininnovative ways - cultivating your problem solving skills and developingplans to provide services despite limited resources and tight budgets. Itteaches you to become flexible and manage your time more efficiently. Itallows you to learn how others are solving similar problems in their work-place.

So when you are asked to participate on your unit, in your clinic,within the facility, in the community, or in a professional organization -take it as a compliment because your ideas are valued. You are importantand needed. Be part of the solution.

This is one dramatic example of volunteerism described by Dr.Deering, a medical volunteer on the island of Jamaica. The case hedescribes is unusual, even in a developing country: a 40-year old womanhad a large ovarian tumor (45 pounds). With scant medical services, thepatient had to wait for surgery until a volunteer team arrived. An obste-trician from the United States excised the benign mass, which turned outto not be so benign. The tumor had been crushing the woman’s venacava, squeezing a great quantity of blood into many clots. Released fromthe pressure, a large clot broke free and lodged in the patient’s lung,killing her. The next day, the obstetrician walked out of the clinic andfound herself surrounded by the patient’s family. She assumed theywould be angry. Instead, they were grateful for the care their familymember had received and that medical staff from other countries werethere to help.

Dr. Deering states, “Whenever I tell that story to another volunteer, Isay, ‘How could you not go back?’” Dr. Deering has made many visits tothe Caribbean island. “I always tell people it’s selfish - We pay our ownway, our room and board, our airfare, we work for nothing, and we comeback feeling like somebody gave us a million bucks.”

If you think about it, you are asked to participate every day. Every dayyou work as part of a team, participating in the team’s efforts. As part ofa team and as a leader (remember–every nurse is a leader), you keep thepurpose, goals, and approach of the team relevant and meaningful byclarifying its aims and values and then ensuring they stick to them. If you

Karen Griffin

continued on page 11

W W W . A A A C N . O R G 3W W W . A A A C N . O R G 3

IIn August, I had the honor of representing AAACN at The

2008 Call Centers Coordination for Pandemic InfluenzaStakeholder Meeting, held in Atlanta, Georgia. The meetingwas hosted by the Centers for Disease Control and Prevention(CDC) Division of Healthcare Quality Promotion (DHQP) andthe Oak Ridge Institute for Science and Education (ORISE).

Those in attendance included professionals from acrossthe country representing emergency preparedness, EMS, poi-son control centers, public health, and call center settings. Itwas a pleasure to discover three other members of AAACNrepresenting telehealth: Carol Rutenberg, RNC, MNSc, PennyMeeker, RNC, and Diane Chamberlain, MS, BSN, RN-BC.

As subject matter experts, community best-practice plan-ners, and key stakeholders, we were brought together for thepurpose of providing community planners with a workbookwhich would guide them through myriad challenges of pan-demic influenza. The workbook will provide guidance to com-munity planners on how to utilize call centers during a pandem-ic influenza.

The first morning was dedicated to four presentations fromexperts, each representing their region’s unique emergencypreparedness plan. While each presentation discussed the dif-ferences in our structure and operations, it was clear that every-one shared the desire and dedication to achieve an improvedstate of readiness. The remainder of the day was spent in smallgroup brainstorming sessions to consider the following: criteriathat communities should consider when planning for coordina-tion of call centers; types of call centers that should be availableand the role they will play; and strategies for coordinating thesecall centers.

The last day was dedicated to further developing ourconcepts, in a large group setting, in an effort to create adraft of the plan. As subject matter experts, each of the atten-dees was assigned to a work group (i.e. human resources,technology, call center expert, communication, etc.), which

would assist in further development of the topic. Those of usrepresenting telehealth volunteered to serve on several of thework groups. We will be called upon in the future to reviewcontent drafted by the CDC and provide feedback duringdevelopment of the workbook.

As I traveled home to St. Louis, Missouri, I reflected on myresponsibility and honor as an ambulatory care nurse to servemy community. Although this group has been called togeth-er to assist in the development of the CDC workbook, each ofus, as ambulatory care nurses, has an opportunity to beinvolved in our communities as they plan and prepare for thepossibility of an influenza pandemic.

Suzanne Wells, BSN, RNManager

St. Louis Children’s Hospital Answer LineSt. Louis, Missouri

A Stakeholder Meeting

Representing AAACN at the 2008 Call Centers Coordination for PandemicInfluenza Stakeholder Meeting was Suzanne Wells (front center). Other AAACNmembers in attendance were (l-r) Diane Chamberlain, Carol Rutenberg, and(back row) Penny Meeker.

Linda Brixey, RN, Joins Board of DirectorsLinda Brixey, RN, program manager, clinical education, at Kelsey-Seybold Clinic, Houston, TX, is a new

member of the AAACN board of directors. Linda has served on the Nominating Committee and ProgramPlanning Committee, co-chaired the Patient Education SIG, and chaired the Staff Education SIG and SIGOversight Committee. Linda is a frequent presenter at the annual conference as well as a contributor toViewpoint. She was a contributing author to both editions of the Core Curriculum for Ambulatory Care Nursingas well as A Guide to Ambulatory Care Nursing Orientation and Competency Assessment. The board of directorsis pleased to have Linda’s extensive background in ambulatory care nursing and leadership in AAACN on theboard. Linda’s expertise will be invaluable in planning for the future needs of the members of AAACN. Lindafills the director position vacated by Nancy Spahr, MS, RN-BC, MBA, CNS.

4 V I EWPO I NT NOV E M B E R/ DEC E M B E R 2008

One of the benefits of AAACNmembership is the ability to submitquestions regarding practice, stan-dards, and other topics via our Website, www.aaacn.org. The questions areredirected to AAACN members whohave volunteered to serve on an“Expert Panel,” and as such haveagreed to respond to these questions asappropriate to their areas of expertise.

In July, a question was submittedwhich created quite a stir. The query ledto a string of responses that raisedquestions about the role of the profes-sional nurse in ambulatory care. A livelydiscussion ensued regarding the differ-ence in the roles among RNs,LPNs/LVNs, and medical assistants(MAs).

The 2009 annual conference inPhiladelphia will close with a “TownHall Meeting,” which will be a facilitat-ed discussion moderated by one of theAAACN board members, MarianneSherman. The discussion will center ondefining the role of the professionalnurse in the ambulatory care settingand answering the question, “How areRN responsibilities differentiated fromthose of LPNs/LVNs, and how are medicalassistants appropriately utilized in ambu-latory care?”

In anticipation of this year’s confer-ence, we would like to share excerptsfrom the string of emails (edited forclarity) that precipitated discussion ofthis important topic.

THE ORIGINAL QUESTION(from Joan Bryar Angeletti, MSN, RN)

Are there any other AAACN mem-bers who work primarily with a medicalassistant model? We are a very largeFQHC (Federally Qualified HealthCenter) and are working on “raising thebar” for our MAs. Thanks!

RESPONSE #1(Eileen Esposito, RNC, MPA, CPHQ)

I am responsible for the ambulato-ry practices and clinics of two large ter-tiary care hospitals. Our model is likelysimilar to yours—we call it a medicalmodel—which consists mostly of physi-cians working with medical office assis-tants. All of our clinics have registerednurses to assure continuity of care asthat model consists of mixed voluntaryand faculty physicians supervising theresident physicians. We use nurse prac-titioners (NPs) as providers in the high-er risk or very specialized practices. Wetry to hire only certified medical officeassistants (MOAs) and verify competen-cy at least annually.

RESPONSE #2(Lenora Flint, RN, PHN, MS, MSN, CNS)

We hire only certified medical officeassistants (MOAs) and verify competen-cy initially and ongoing. Competencyoutcomes are integrated into the annu-al performance review process. The his-toric challenges we have experiencedare MAs working outside their scope of

work and RNs not working up to theirfull scope of practice and accountabilityand abdicating to MAs. Much haschanged (yet there is still a lot of workto do) over the past three years,through initiatives to:

• Review, educate, and hold MAsaccountable to their legal scope ofwork.

• Review, educate, and hold RNsaccountable for their full scope ofpractice.

• Educate physicians regarding MAscope of work vs. RN scope of practice. We continue to work on an RN

development program. This programwill include strategies to transition RNsappropriately away from the office tele-phone triage process by delineatingwhich calls can be managed by an MAor LVN, and which calls require RNtriage. The goal is to have the RNsrounding, coaching, and supervising,and assuring staff are competent.Achieving continuum of care activitiesand stellar customer service is also partof the RN role. In other words, we aredriven to have RNs working to thefullest extent possible of their scope ofpractice.

RESPONSE #3(Joan Pate, MS, RN)

There are limitations to the scope ofpractice of medical assistants in the clin-ical setting, in that they do not assess orevaluate patient’s responses to treat-ments, medications, etc. Utilizing otherlicensed personnel (RNs, LPNs) for morecomplex nursing care would providethe additional support specialty clinicsand primary clinics will need. In contrastto the medical model is the nursingmodel of clinic management, wherethere are fewer MAs and more licensednurses. This is where RN-managed clin-ics are established for the high risk,problem-prone patient populations.Licensed nurses cost more than medicalassistants, and the bottom line mostoften drives which model is used. In myexperience managing multiple clinics,the nursing model has been most suc-cessful in not only providing a safepatient environment, but also in achiev-ing greater compliance to the standardsof ambulatory nursing practice.

First and foremost, it’s essential thatwe recognize (and appreciate) the dif-ferences among RNs, LPNs/LVNs, andmedical assistants (MAs). We then needto identify what the patient needs are inthe ambulatory care setting and deter-mine which level of education, training,and licensure is required to meet each ofthose needs. We should then advocatefor utilization of all personnel to theirmaximum (legal and competency-based) potential.

• We must identify those elements ofcare which require RN licensure andassign those responsibilities to theRNs. This promotes utilization of theRNs to their fullest potential, such asin nurse-managed clinics; utilizationof RNs to assure continuity of care;and telephone triage, which requiressignificant critical thinking and clini-cal judgment.

• Once the care that requires an RNlevel of preparation and licensure hasbeen delegated/assigned to the RNs,all other licensed nursing activities(not requiring an RN license) couldbe delegated to the LPNs/LVNs.

• And then all other care, not requiringlicensure, could/should be delegatedto MAs, keeping in mind previouscomments regarding the fact thatdifferent states and different levels ofpreparation have differing delega-tion requirements. We must also bevery clear on whether these taskscan be delegated and supervised byRNs or if they must be delegatedand supervised by physicians.

W W W . A A A C N . O R G 5

RESPONSE #4(Joan Bryar Angeletti, MSN, RN)Thanks for your response to my inquiry.We are currently exploring and advocat-ing for raising the bar via a clinical lad-der and providing prep courses for cer-tification and future career paths tolicensure as an RN or LPN. We are faced,though, with various practices through-out the organization in which MAs maybe practicing out of their scope as aresult of acquisitions of formerly privatephysician practices. Change is difficultand the role of our department is to pro-vide the leadership and education tobring the MA practice throughout theorganization on the same page withinthe MA scope of practice both with theMAs and the providers.

RESPONSE #5(Carol Rutenberg, RNC-BC, MNSc)

As a consultant, the overwhelmingtrend I see relative to your query has todo with misuse of personnel at all levels.One of the greatest challenges facingambulatory care nursing today is theneed to clearly define the role of theambulatory care nurse in the office/clin-ic setting. We all know what nurses doin the hospital and other inpatient spe-cialty areas, but when we get into theclinics, we are often faced with a culturethat tolerates calling any woman inscrubs a “nurse.” And unfortunately,due to poor role differentiation in manyorganizations, there’s little ostensibledifference in the practice of thosewomen (sic—sorry, guys).

We must use extreme caution inwhat telephone tasks we delegate tonon-RNs. I agree that nurses must giveup some of our sacred cows. Faced withour current nursing shortage and thecertainty that it will get much worse inthe near future, we must be lookingahead to what care can be safely pro-vided over the phone or internet andbegin to develop processes to supportthat type of remote care by appropri-ately trained and licensed individuals.While there is a temptation for RNs tohang onto things we traditionally didn’tbelieve could be delegated (such ascalling for lab results and taking infor-mation regarding prescription refills,etc.), I believe that there has been aneven greater temptation for nurses,without adequately considering theimplications, to give away tasks thatshould be handled by RNs because ofpatient safety implications.

For example, I strongly believe thatRNs should triage patients who requestsame day appointments or otherwisehave acute symptoms. While somemight argue that this approach advo-cates utilization of RNs as “glorifiedappointment clerks,” I disagree.

• The decision re: whether a patientshould be seen today or can waituntil tomorrow requires criticalthinking, and when the wrongdecision has been made, it has costpatients their lives.

• Significant clinical judgment is often

2008 Corporate Members

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continued on page 13

Research GrantsMembers are invited to submit a

research abstract for considerationshowing proof of acceptance of theresearch study by an academic institu-tion or by an Investigational ReviewBoard of the employing or sponsoringinstitution. Findings will be shared atthe AAACN Annual Conference and/orpublished in an article in Viewpoint.Amount of grant varies.

Excellence AwardsTwo awards are presented and are

sponsored by the Nursing Economic$Foundation. Each award consists of$500 and a plaque.

• The Administrative ExcellenceAward recognizes a member’sunique ability to lead others towardthe successful completion of theirorganization’s/work place’s missionand goals.

• The Clinical Excellence Award rec-ognizes a member’s excellence innursing skills, knowledge, expert-ise, and personal attributes thatcontribute to the delivery of qualitypatient care.To apply for an award or scholar-

ship, visit the “Awards” section of theWeb site at www.aaacn.org (under the

AAACN Welcomes New Group Members

Many facilities are realizing theadvantages of paying for their nurses tohold memberships in professional nurs-ing organizations. The advantages tofacilities are too numerous to list, but afew are: retention through nurse satis-faction; a feeling of worth that theemployer values its nurses and supportscontinued learning; better patient out-comes; enhanced leadership skills; anddiscounts on the ambulatory care nurs-ing certification exam and study materi-als. The Cleveland Clinic has participat-ed in the Group Membership Programfor three years and enrolls over 200nurses annually. AAACN is proud to wel-come the nurses from two new facilitiesunder our Group Membership Program:

• Children’s National Medical Center,Washington, DC

• SUNY Downstate Medical Center,Brooklyn, NYLet AAACN help you educate and

keep your valued nurses by learningmore about our Group MembershipProgram which offers a reduction inmembership dues for facilities enrollingand paying for 25 or more nurses.Download a fact sheet about groupmembership at www.aaacn.org or e-mail reichartp@ajj.com for more infor-mation.

Scholarship/AwardsApplication Deadline -

January 15AAACN’s scholarship program sup-

ports the advancement of ambulatorynurses and nursing practice throughthe provision of scholarships andresearch grants. Funds are raisedthrough the annual Silent Auction andprivate donations. Applying for theseawards is a very simple process.

ScholarshipsMembers enrolled in an accredited

school of nursing or a program deemedto advance the profession of nursingmay be awarded a scholarship up to$1,000 to cover the cost of tuition,books, or academic supplies.

“About AAACN” tab) or call 800-262-6877 to request an application.

New Electronic Renewal Notices

In conjunction with AAACN “goinggreen” at the 2009 conference, renewalnotices will be e-mailed to memberswho have given us e-mail addresses. Ifyour membership expires on December31, 2008, you should have received yourrenewal notice via the e-mail address thenational office has on file for you.

In addition to saving a few trees,this new method will also save onpostage, which will allow us to keepmembership costs down. This new pro-cedure will be used on all future renew-al notices as well. We encourage you torenew your membership online beforethe end of the year, to ensure yourmembership benefits are uninterrupt-ed. If you do renew by December 31,you will be entered into a drawing towin a renewal of your membership foran additional year – through December31, 2010. Five renewals will be award-ed. A new two-year dues option savesmembers $20 when they renew or joinfor two years. AAACN thanks all mem-bers for their continued support.

6 V I EWPO I NT NOV E M B E R/ DEC E M B E R 2008

AAACNN E W S

Educate Your Staff on Current Telehealth Practices

Instructors for the newly updated TelehealthNursing Practice Core Course (TNPCC) will be ready totake the course “on the road” beginning in the earlypart of 2009. This course is an excellent way to orientnurses new to telehealth practice, enhance knowledgeof telehealth practice, and provide staff education andtraining in telehealth nursing. The course is an excel-lent resource for nurses providing telehealth care inany setting. To find out how to bring this course toyour facility, contact reichartp@ajj.com or call 800-262-6877.

The 3rd edition of the Telehealth Nursing PracticeCore Course Manual will also be available in the earlypart of 2009. The manual will offer approximately16.6 contact hours and will detail the nursing com-petencies essential for delivering care to patients via telecommunications tech-nologies. The manual is ideal for orienting nurses new to telehealth practice,understanding practice issues related to telehealth nursing, and developing theskills necessary for successful telehealth practice. Watch for announcements ofthis updated resource early next year.

“Three Amigos” Take Ambulatory Care Nursing

Certification Review Course On the Road

Candy Laughlin, E. Mary Johnson, and SusanPaschke, known by some as the “three amigos,” arealways on the alert to travel across the country to teachthe Ambulatory Care Nursing Certification ReviewCourse. These instructors traveled seven weekends in2007 to teach the course, most recently at James A. HaleyVA Medical Center in Tampa, FL, and at the University ofMichigan Hospital on two consecutive weekends.

Kaiser Permanente in Southern California has alreadybooked the course for May 2009 to prepare its nurses totake the Ambulatory Care Nursing Certification examafter it converts to a new electronic format in April 2009.These three instructors will also teach the course onThursday, March 26, 2009, at the 34th Annual Conferencein Philadelphia, in preparation for the Ambulatory CareNursing Certification Exam on Sunday, March 29. Thecourse is also available on CD-ROM and offers 7.3 contacthours.

If your facility is promoting certification to its nurses,you may want to consider hosting an Ambulatory CareNursing Certification Review Course at your facility. Thecost to host the course averages around $5,000. Thesecosts could be shared if a facility invites a nearby facilityto co-host the course. Hosts of a course may also invitenurses from a nearby facility to attend and charge a fee toregister. This fee is determined by the host. Contactreichartp@ajj.com to learn how you can bring the courseto your facility.

W W W . A A A C N . O R G 7

Date: Wednesday, 1/21/09Time: 10:00 a.m. Pacific, 11:00 a.m. Mountain,

12:00 p.m. Central, 1:00 p.m. EasternMember Price: $99 memberRegular Price: $129 non-memberCNE Credit: 1.25 contact hours*Presenter: Dorene Sullivan, RN, Patient Care

Manager Anticoagulation ManagementServices, Carle Clinic, Urbana, IL

What is the role of the ambulatory nurse whenworking with a patient on anticoagulants? The presen-ter will review key triage questions and documentationrequirements for patients on anticoagulants. In addi-tion, identification of quality assurance and risk man-agement issues and how they relate to monitoringpatients taking oral anticoagulants will be addressed.We’ll also include the development of patient educationmaterials and the key points to be included when doc-umenting patient education.

Visit www.aaacn.org to download a registrationform or call 800-262-6877 to request the form. A CD-ROM of the seminar will be sold in the AAACN store fol-lowing the seminar.*This educational activity has been co-provided by AAACN andAnthony J. Jannetti, Inc.

Anthony J. Jannetti, Inc. is accredited as a provider of continuing nurs-ing education by the American Nurses' Credentialing Center'sCommission on Accreditation (ANCC-COA).

AAACN is a provider approved by the California Board of RegisteredNurses, provider number CEP 5336. Licenses in the state of CA mustretain this certificate for four years after the CE activity is completed.

Anticoagulation ManagementServices (AMS) LIVE Audio Seminar

in January Earn 1.25 contact hours!

Online Registration is NOW OPEN for the

AAACN 34th AnnualConference

March 26-30, 2009Philadelphia MarriottPhiladelphia, PA

EEaarrllyy BBiirrdd DDeeaaddlliinnee --FFeebbrruuaarryy 99,, 22000099

Visit www.aaacn.orgto register.

The “Three Amigos” (from l-r): Susan Paschke, E. Mary Johnson, CandiaLaughlin

8 V I EWPO I NT NOV E M B E R/ DEC E M B E R 2008

rapid turnaround time for home testing and up to two-hourwaits for traditional laboratory testing resulted in patientand practitioner frustration. In 1994, bowing to pressurefrom the public, physicians, and in particular diabetologists,the Clinical Laboratory Standards Institute (CLSI) publishedclinical guidelines for ancillary (bedside) blood glucose test-ing in acute and chronic care facilities.

The third major influence in point of care testingoccurred when Congress passed the Clinical LaboratoryImprovement Amendments in 1988 (CLIA) which estab-lished quality standards for laboratory testing. These regula-tions provided the framework for central laboratories todevelop standardized policies, processes, rules, and proce-dures related to guidelines for training; demonstrate compe-tency and proficiency; and monitor point of care testing. Thestandardization allowed for more consistent and reliable out-comes of testing and reduced variation in technique.

The guidelines also encouraged standardizing equip-ment within facilities to promote consistency in testing pro-cedures between departments, floors, and units. These newstandards were especially important in large facilities inwhich one department (e.g., the emergency department)would conduct a finger stick glucose test but anotherdepartment would act on the results. The goal was to cre-ate a common understanding of the result range in order toprovide excellent care across the continuum.

Types of POCTThere are several categories of POCT ranging from

waived testing to highly complex testing. Waived testing isthe simplest of all POCT. Tests can be categorized as“waived” from regulatory oversight if they meet certainrequirements established by the CLIA. Examples of waivedtests include fecal occult blood testing, blood glucose fingersticks, and any test that is meant to be performed at homeby consumers, such as urine pregnancy tests.

Point of care testing performed in physician offices,physician office laboratories, clinics, and hospitals is regulat-ed under the CLIA law and the site must be licensed to per-form any testing. A site that only performs waived testsmust hold a “Certificate of Waiver” license, follow all man-ufacturers’ guidelines for testing, and demonstrate appro-priate use of controls to assure accurate testing. These sitesare not routinely inspected by regulatory agencies such asthe Department of Health (DOH) or the College ofAmerican Pathologists (CAP).

Sites that perform more complex testing known as“moderate complexity” and “high complexity” must belicensed and routinely inspected. In most cases, the site isrequired to establish quality assurance monitoring pro-grams and follow medical record documentation guide-lines. For example, when performing a urinalysis on a clini-cal tabletop analyzer, controls are run at the beginning ofthe day to assure the analyzer’s functionality and accuracy.Two identifiers, such as the patient’s name and date of birth,are documented in the medical record along with the test

results and the normal result range. A testing log is alsomaintained as a cross reference to expedite patient identifi-cation in case of product recall.

To create a safe environment for POCT within hospitalsand other health care facilities, Kiechle recommends follow-ing the “Five Golden Rules”:

1. Establish a POCT Committee to make all POCT deci-sions related to the expansion of existing programs orthe initiation of any new programs. This committeeshould include a pathologist, an administrator, nursingor other clinical staff, and the POCT coordinator.

2. Standardize on one device per point of care test. Thisstandardization will greatly reduce errors that are relat-ed to variation in required technique and result range.

3. Establish a strong quality assurance/quality control pro-gram with consistent processes and requirements forcontrols, logs, and documentation. Policies and proce-dures that require immediate action for addressing outof range results are an important aspect of this pro-gram.

4. Assure adequate staff training with one-to-one returndemonstration. Conduct periodic competency assess-ment and proficiency testing as required by regulationand standards.

5. Utilize centralized connectivity to ensure ease of over-sight by the POCT coordinator/supervisor. This includesrecording results into the lab database and billing sys-tems and communicating results to all practitioners in atimely manner.

Advances in TechnologyIn addition to standards and regulations, technologic

advancements have paved the way for improvements inpoint of care testing. For example, the introduction of tech-nology to perform point of care INR testing (InternationalNormalized Ratio = ratio of a patient’s prothrombin time toa normal) has made dramatic improvements in the antico-agulation status of many patients. Point of care testingallows practitioners to make decisions about changes in apatient’s care plan while they are still in the office, allowingmore patients to attain and maintain stable anticoagulationstatus without untoward effects. Centers for Medicare &Medicaid Services (CMS) has enacted recent billing andcoding changes to allow for evaluation and monitoring ofhome INR testing for certain patient conditions that requirechronic anticoagulation, such as a mechanical heart valve.The Institute for Healthcare Improvement, long known forthe promotion of safe patient care practices, recommendscreation of anticoagulation clinics run by nurse practitionersor pharmacists utilizing rapid turn-around testing or POCTfor optimal outcomes.

Changes in technology have resulted in smaller, easier-to-use analyzers equipped with biosensor elements. Thisenhanced technology coupled with single-step cartridge ortesting strips that require minimal amounts of blood orbody fluid have revolutionized point of care testing for mil-lions. In 2005, over 6 million POCT lab tests were per-formed in hospitals. This number is expected to grow to 1.2billion by 2011.

Point of Care Testingcontinued from page 1

Future directions suggest that POCT growth is inevitableas technology naturally evolves toward extension and minia-turization. Many factors, including demand for reimburse-ment, increased need for access to testing in non-traditionallocations (e.g., biohazard threat treatment locations), andpressure from consumers, practitioners, and others, will con-tinue to reinforce the need for point of care testing and tech-nology.

Suggested ReadingsAmerican Society for Clinical Laboratory Science. (1996). Point of care.

Position paper. Retrieved September 26, 2008, fromhttp://www.ascls.org/position/point.asp

Centers for Disease Control and Prevention. (2004). Clinical LaboratoryImprovement Amendments (CLIA). Retrieved October 6, 2008,from http://www.cdc.gov/clia/default.aspx

College of American Pathologists. (n.d.). Point of Care Testing Definitionand FAQs. Retrieved September 26, 2008, fromhttp://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel

=cntvwrPtlt&cntvwrPtlt{actionForm.contentReference}=committees%2Fpointofcare%2Fpoc_applicability.html&_state=maximized&_pageLabel=cntvwr

Foss-Bowman, C. (2007, November). Point of care testing: Past, present,future. Conference presentation at North Shore-LIJ Health SystemMedical Grand Rounds, Great Neck, NY.

HemoSense, Inc. (2007). Reimbursement Guide for the INRatio for thePT/INR Monitoring System. San Jose, CA: AUTHOR.

Institute of Healthcare Improvement. (2008). Reduce adverse drug eventsinvolving anticoagulants: Develop a Warfarin dosing service or clinic.Retrieved October 3, 2008, from http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Changes/IndividualChanges/Develop+a+Warfarin+Dosing+Service+or+Clinic.htm

Medscape.com. (n.d.). Point-of Care-testing: Past, present and future.Interview: Frederick L. Kiechle, MD, PhD. Retrieved September 9, 2008,from http://medscape.com/infosite/pointofcaretestiing/article-1

Eileen M. Esposito, RNC, MPA, CPHQ, Assistant Executive Director,Ambulatory PCS & Quality, AAACN Member, Nursing Representativeto College of American Pathologists Point of Care Testing Committee.

Find it today in the American Academy ofAmbulatory Care Nursing (AAACN)

Career Center. • Learn about your personal work style to

identify your optimum work environment. • Find the right job from the most

comprehensive listing of ambulatory care andtelehealth nursing opportunities.

• Respond to opportunities directly online or postyour CV or resume.

• Sign up for “Job Alerts,” instant notifications of new listings that match your criteria.

See our list of the best and the brightest ambulatory care nurses and

health care professionals.

• Recruit with ease! Hone in on your preferredcandidates, all in one place.

• Take advantage of volume pricing discounts.• Sign up for “Resume Alerts,” instant

notifications of new candidates that match your specific criteria.

• Access personal customer care consultants.

American Academy of Ambulatory Care Nursing

Phone: 800-AMB-NURS (262-6877)E-mail: info@healthecareers.com

The AAACN Career Center is a proud member of theHEALTHeCAREERS Network

of health care association online career centers.

www.aaacn.org(Click on the “Jobs” tab)

AAACN Holds Fall Board of Directors MeetingThe AAACN board of directors held its fall

meeting at the Pitman national office. AAACN staffmembers explained their responsibilities in sup-porting AAACN to new board member, LindaBrixey, RN. (See page 3 to learn more about Linda.)

The board met for two days, and the maintopic of discussion involved strategic planning andthe best method to use in developing a new strate-gic plan to guide AAACN’s future.

Also attending the board meeting wasAAACN’s Investment Advisor who reviewedAAACN’s investment status. Additional topics ofdiscussion included the third quarter financial report, revision of the Ambulatory Standards, Telehealth Standards, and Review Questionspublications, editor evaluations, new ambulatory nurses logo products, revisions to the Bylaws, marketing plans, approval of theOperating Budget for 2009, and more.

10 V I EWPO I NT NOV E M B E R/ DEC E M B E R 2008

Many great things happened at AAACN’s 33rd AnnualConference in Chicago in April 2008. One importantadvancement occurred with the formation of the LegislativeCommittee. Members include:

To support ambulatory care nurs-ing in a legislative role, the committeehas established four objectives whichalign with AAACN goals.

Goal: Knowledge: AAACN will be therecognized source of knowledge inambulatory care nursing. Objective: The Legislative Committeewill review legislation. Both federal andstate issues will be brought to the com-mittee by organizations like Americansfor Nursing Shortage Relief (ANSR) coalition. ANSR is led pre-dominately by a few of the larger nursing organizations thathave legislative representatives whose full-time jobs involve leg-islative advocacy. Often AAACN is asked to sign on to letterswritten by the ANSR which can effect legislation related tofunding for nursing education programs. AAACN members,other organizations and political groups requesting AAACN’ssupport, endorsement, or standing on various topics or issuesare other channels of legislative awareness for the committee.The requests for support or endorsements will be relayed in atimely manner to the Board and AAACN membership, whenapplicable.

Goal: Education: Nurses will have the leadership skills andcapabilities to articulate, promote, and practice nursing suc-cessfully in an ambulatory care setting. Objective: The Legislative Committee will provide the AAACNBoard of Directors and AAACN members with the educationneeded to more fully understand the legislative process.

Goal: Advocacy: The healthcare community will recognize andvalue ambulatory care nursing.Objective: The Legislative Committee will increase its knowl-edge of issues that relate to or affect ambulatory care nursing.This will result in identifying a specific work plan that will rec-ognize the expertise of the AAACN Legislative Committee.

Goal: Community: Ambulatory care nurses will have a support-ive and collaborative community in which to share profession-al interests, experience, and practice. Objective: The Legislative Committee will increase awarenessof its work and engage other AAACN members to join.

In three short months the Legislative Committee has beenactively involved in reaching its goals. Members have sharedopinions on education with the Board for its review and actions.The chair has consulted with the American Nurses Association(ANA) and the Alaska Nurses Association. The chair also hasappointments with one state and one federal lobbyist. Eachcommittee member is reviewing their state’s legislative infor-mation.

To keep AAACN members informed, the LegislativeCommittee will provide updated information about legislationand work the committee is doing in each issue of Viewpoint.Any AAACN member who is interested in joining the LegislativeCommittee should contact Chairperson Pat Reynaga atPatricia.Reynaga@providence.org or Co-Chairperson AngeliaElum-O’Neal at angelia.elum-oneal@med.navy.mil

We look forward to a year of making OUR VOICE COUNTfor ambulatory care nursing.

Julie Long, RNCManager, University Health Service Center

University HospitalAugusta, Georgia

Legislative Committee ChairPat Reynaga

Chairperson, Pat Reynaga, RNCo-chair, Angelia Elum-O'Neal,

RN, MSEdBoard Liaison, Belinda Doherty,

MBA, BSN, CPURGail Ausbrooks, BSN, RNNancy Barr, RNTonja Belo, BSN, RNMaryrose Coughlin

Marlene Grasser, RNMaria G. Guevara De MatalobosJane Hummer, BSN, RN, MPHDoni Jennings, ASN, RNJulie Long, RNCCatherine Rhodes, MSN, CNPMichele Shelton, BSN, RN, BCSandra Sutton, RNMary Vinson MS, RN-BC, CMPE

Our Voice Counts

AAACN Board of Directors and staff

Patient Education SIG

DHHS HealthFinder Web Site UpdatedThe Department of Health and Human Services has

recently updated the HealthFinder Web site(http://healthfinder.gov) with new interactive health man-agement tools and personalized recommendations(myhealthfinder) for preventive health screenings based onan individual’s age. This project is coordinated through theOffice of Disease Prevention and Health Promotion withinput from federal agencies, consumer health informationspecialists, and librarians. Users have access to an encyclo-pedia with over 1,600 health topics, health news, and per-sonal health tools. The Web site also includes information inboth English and Spanish.

Prepare for Flu Season with New Educational ComicBook

To promote awareness and preparation for pandemic flu,The Public Health Service in Seattle has developed a 12-pagecomic book for readers of all ages which tells a family’s storyin the 1918 pandemic flu outbreak. The booklet, No OrdinaryFlu, discusses the threat of a world-wide influenza outbreaktoday, how to prepare, and is available in several languages.To order copies, visit the National Association of County andHealth Officials Web site, www.naccho.org/publications, andsearch the alphabetical list.

Leadership SIG If you attended the spring 2008 Annual Conference in

Chicago, we hope you made it to the Leadership SIG meet-ing. We enjoyed a wonderful exchange of information andwe have continued the conversation on our list serve sincethen. The discussions have shared information on such top-ics as policy, wage scales, regulatory issues, operating sys-tems, and much more!

The Leadership SIG leaders have been very active sincethe conference. Working with other members, we havedeveloped five sessions (totaling seven hours) that will beoffered in a Leadership Development Track threadedthroughout the 34th Annual Conference in Philadelphia,March 26-30, 2009. Watch for our titles: Service Excellence;Emotional Intelligence (interactive two-hour workshop);Business Planning: How to “Sell” An Idea to UpperManagement (two-hour workshop); and Financial Health:Connecting the Dots in the Pay for Performance Maze.We’ll also be hosting Ask the Experts: A Panel Discussion,which will give you an opportunity to ask leaders thosequestions you always wanted to ask, but never had a forum.

The Leadership SIG is proud to facilitate theseLeadership Development sessions in response to requestsfrom AAACN members.

We look forward to seeing you in Philadelphia!Margarita Gore, MBA, BSN, RN, BC

Operations Manager, Dept of NeurologyMayo Clinic, Scottsdale, Arizona

W W W . A A A C N . O R G 1 1

work on a unit, don’t you get a morning report eachday and then organize your day/make assignments asneeded? If you work in a clinic, don’t you review thenumber of patients, what procedures might be done,how many new patients will be seen?

As part of the team, you build commitment and con-fidence in team members – giving praise when it is dueand constructive criticism when needed. You look atprocesses when things go wrong and fix those processes.As part of the team, you look at the skills needed by teammembers and facilitate/suggest training to meet thoseneeds. As a part of the team, you manage relationshipswith outsiders (other employees, families, and supportservices) and remove obstacles from the team’s path(problem-solve with the team and participate). You shareopportunities with other members for growth and renew-al. And as part of the team, you make sure everyone con-tributes equally to the task. This is basic participation.

I challenge you to do more in your facility, in yourcommunity, and in your profession, because volunteeringand participation are actions that make you and the asso-ciation remarkable.

Karen Griffin, MSN, RN, CNAA, is Deputy Associate Director forPatient Care Services/Nurse Executive, Valley/Coastal Bend Division,South Texas Veterans Healthcare Systems, San Antonio, TX. She maybe contacted via e-mail at kfgriffin@hotmail.com.

President’s Messagecontinued from page 2

S IGNEWS

At Ministry Health Care, the leading network of hospitals, clinics, long-term care and home care agencies in Wisconsin, saving the day forour patients is what we do every day. Our dedicated professionalsdeliver the most advanced treatments, in the most caring way. In turn,we reward and recognize them every chance we get.

CLINICAL NURSING SERVICES DIRECTORMinistry Medical Group - Central Region (Stevens Point, Wis.)

In this role, at Ministry Medical Group, you will provide advice,consultation and recommendations to senior leadership in regard tonursing policies, procedures, practices, standards, education and staffdevelopment. You will also serve as the nursing liaison with seniornursing leadership at Ministry Health Care entities as well as promoteand support the process of quality improvement in patient care.

Requires a BSN (or commitment to achieve a BSN within two years)and five years of nursing experience. A license to practice inWisconsin, an LSS Green Belt (or achieve within one year) andleadership experience is essential. An MSN and three years ofexperience in a multi-disciplinary clinic setting is preferred.

Equal Opportunity Employer

Apply online at: ministryhealth.org

today. tomorrow. together.TM

Be a part of our heroic team.

everydaySaving the day

• Treatments: What has been triedthat decreases/increases symptoms?

• Medications: Review all medica-tions, including over-the-counterand alternative. It is important toidentify amount and frequency.

• Female patients: If childbearingfemale, ask about last menstrualperiod - Was it usual? Are you preg-nant or breastfeeding?

• Ask caller when last bowel move-ment occurred.

• Does the patient smoke?• Ask caller when was last provider

visit.By using this template, the nurse

methodically gathers informationresulting in a thorough assessment. Justas important, this tool also helps thepatient organize his or her thoughts.Often, a patient will pause and contem-plate the question and then respond,offering more detail than what wasoriginally presented. This guided con-versation helps the nurse sort the symp-tom information and gain understand-ing of the patient’s experience.

Without a template or information-gathering tool, patients may uninten-tionally leave out key pieces of informa-tion that would create an incomplete orinaccurate impression. And nurses maynot ask enough questions to get essen-tial information.

The patient who is reserved, quiet,hesitant, anxious, or intimidated mayinadvertently seem vague over thephone. The partnership between thenurse and patient is essential for thecompletion of the picture. When all thetechniques and tools are implemented,a precise, authentic, original image canbe created.

Kathryn Koehne, RNC-TNP, is a NursingSystems Specialist, Department of NursingPractice, Gundersen Lutheran Health System.She may be contacted via e-mail atkrkoehne@gundluth.org.

12 V I EWPO I NT S E PTE M B E R/OCTOB E R 2008

I

12 V I EWPO I NT NOV E M B E R/ DEC E M B E R 2008

TelehealthTr ia l s&Tr iumphs

Vague CallerI often use the metaphor of an artistpainting a masterpiece to describe thetelehealth triage process. The nurse isthe artist. The patient situation is thesubject of the painting. The palette ofcolors is the telehealth template. Thebrushes are the communication toolsthat a telehealth nurse utilizesto obtain information and thenrelay it. The easel which sup-ports the canvas is theTelehealth PracticeStandards, NursePractice Acts,decision supporttools, and profes-sional resources andreferences.

At the initiation ofeach call encounter,the canvas isblank. Thenurse beginsthe triageprocess; thepatient relayskey information. Asthe call progresses with anexchange of dialogue, an imageappears. What was colorless now has animage. With the addition of moredetail, the form begins looking recog-nizable.

The above is a description of aclear, straightforward triage process.The patient reports symptoms and thenurse sorts the information. Guidelinesare utilized and a plan developed.

However, sometimes the pictureisn’t so clear…

The nurse (artist) is attempting toguide (paint) the patient situation(image). He or she is utilizing the mostrefined of communication skills (brush-es) yet the canvas has few strokes. Thisis the case of the “vague caller.” Everyexperienced telehealth nurse hasencountered this particular challenge.The nurse asks many questions and thepatient responds, but the answers donot lead to clarity.

The following scenario will illus-trate this situation.

A patient calls thephysician’s office or callcenter seeking adviceregarding a particular

symptom or groupof symptoms. Youobtain their demo-graphic informa-tion. This may bethe only clearpart of the dia-logue. Thecaller asks aquestion orreports symp-

toms in an indeci-sive or sketchy manner. Thecaller hesitates, seems uncer-tain in the conversation, and

fumbles as she attempts toexplain the situation. You want to

gather information in an organized,thorough manner and know that youhave to take control of the call. You uti-lize the nursing process and begin yourassessment.

An Assessment TemplateDuring a patient call, a nurse focus-

es on each symptom and carefully doc-uments what the patient relays. Thefollowing template is instrumental inmaking an assessment of the patient’sstatus.

• Begin call: Tell me about your con-cern today? (open-ended)

• Onset: When did this begin? • Location: Identify specific location. • Description: Tell me what you are

experiencing.• Pain/Rate: Ask caller to describe

pain and explain pain rating scale.• Precipitating Factors: What caused

this problem?• Associated symptoms: What else

are you experiencing?

Watch for New Web SiteDesign in the New Year

Web designers at the National Office have been workingdiligently on a new look for the AAACN Web site,www.aaacn.org. More importantly though, the site will beeasier to use than ever!

Find and share information with...• Quicker loading times on every page• New drop-down menus that instantly show you what

each section of the site holds• Shortcuts to the most frequently accessed pages• An improved site map• Pages that are printer-friendly

We invite you to visit the new www.aaacn.org in thenew year to see how much easier it is to find an array ofinformation to support your practice and enhance your edu-cation.

W W W . A A A C N . O R G 1 3

necessary to identify those patients who should be seenin the ER instead of coming into the clinic.

• There are some patients who could safely be cared forat home (and would prefer home care if it were offered),but these patients must be carefully assessed and givensufficient education and instructions to assure safe careat home.

• And finally, if the patient requesting a same day appoint-ment is indeed given a same day appointment, clinicaljudgment is often necessary to determine whether con-tinuity of care is the primary concern and thus thepatient should be appointed to his/her primary careprovider (PCP) or if time is of the essence, an earlierappointment with someone other than his/her PCP.

To summarize my observations and considered opinionre: nurses in the office/clinic setting:1. The roles of RNs, LPNs, and MAs are often blurred, with

all levels of personnel often being utilized in essentiallyidentical roles.

2. RNs must be responsible for all care that requires assess-ment, diagnosis, planning and evaluation, and othertypes of critical thinking.

3. RNs are usually grossly underutilized (or misutilized).4. LPNs are valuable assets, but the tasks delegated to

them must be consistent with their scope of practice.5. All skills/tasks not requiring a license should be delegat-

ed (by the appropriate personnel) to well-trained MAs,for whom competency is routinely assured.

6. Careful attention must be given to what tasks may bedelegated to MAs and by whom. And remember that ifthe MA is working under the license of the physician(which is often the case), the physician must also hire,train, supervise, and otherwise assure quality of theseindividuals; otherwise, if the RN provides these supervi-sory responsibilities, this makes the RN responsible forthe care provided by the MAs.

RESPONSE #6(Mary Vinson, MS, RN-BC, CMPE)

The responses to this query have been powerful andreflect the importance of the issues of role clarity in ambulato-ry care. With this much interest generated from a single e-mail, it seems we should begin thinking about a consensusmodel for ambulatory care nursing. The first national consen-sus model for advanced practice nurses has just emerged. Thetime is right. Are we up to the challenge?

Please make plans to attend the Town Hall Meeting atthe 2009 Annual Conference in Philadelphia and join in thediscussion on this critical topic (see box at top of this page.).If you have additional comments on this topic, you maye–mail responses to AAACN Association Services ManagerPat Reichart at reichartp@ajj.com.

Carol Rutenberg, RNC-BC, MCScPresident

Telephone Triage Consulting, Inc.Hot Springs, AR

Defining the Rolescontinued from page 5 Town Hall Meeting

Sunday, March 30, 200911:30 a.m.-12:30 p.m.

at the AAACN 34th Annual Conference

Philadelphia, PAEarn 1.0 contact hour

Make plans to attend the Town Hall Meeting andjoin in the discussion on defining the role of the

professional nurse in the ambulatory care setting.

14 V I EWPO I NT NOV E M B E R/ DEC E M B E R 2008

It is a privilege to introduceSandy Sutton, BSN, RN,C, AAACNmember and an ambulatory nursewho has truly “come up through theranks.” Sandy started her nursingcareer as an LPN in 1981. In 1990,she moved to Florida and beganworking on an OB/GYN unit. “I wasfortunate to work with a wonderfulnurse manager who encouraged allthe LPNs to go back to school tobecome RNs. As a single mother of two children, returning toschool was challenging. However, I graduated in 1998 withan associates degree in nursing,” Sandy explains. Committedto the concept of lifelong learning, Sandy returned to schooland achieved her dream of a bachelor’s degree in nursing,graduating Suma Cum Laude in summer 2008.Congratulations, Sandy!

As her children moved into their teenage years, Sandylooked for a nursing position that would keep her closer tohome. She found school nursing and worked in a programthat provided education for students who were deaf andblind. Eventually she found her way to her current positionwith the North Florida/South Georgia Veterans HealthSystems, working in a large multi-specialty clinic.

Making the change from inpatient nursing to the ambu-latory setting was a challenge for Sandy. She writes, “Havingspent most of my nursing career as a hospital nurse prior tojoining the VA eight years ago, ambulatory nursing was awhole new world. While I was working in a leadership role inprimary care, a nurse from another clinic told me aboutAAACN. I had been looking for help trying to understand theunique role of the ambulatory care nurse, and I found thathelp on the AAACN Web site. Once I began navigating thewebsite, I was hooked. I found that AAACN provides a wealthof information to nurses just entering the ambulatory caresetting as well as to those who have been practicing in thatarea for many years.”

Sandy enjoys working within the VA system because itoffers so much diversity. “Our patients range from youngadults to the elderly. We are often faced with a multitude ofdisorders that the everyday nurse may never see in their prac-tice. Staying current and making lifelong learning a priority isimperative to meet the challenges of our patient popula-tion,” Sandy relates.

Currently, Sandy works in a large women’s clinic thatprovides a wide range of primary health care services. Sheenjoys the fact that the medical records are completely com-puterized, which makes following the patient through alltheir speciality appointments much easier. “Comprehensivecare and follow-up is very important in today’s global socie-

REA

L ty and some of our veterans enter our system only to receive‘call up’ orders. We may lose them for a few months to a fewyears, but we can resume care when they return withouthunting for that paper chart,” Sandy explains.

Sandy remembers the first AAACN conference she everattended. “Since I live in northeast Florida, I was able to driveto my first conference which was in Atlanta. From themoment of check-in to the last speaker, I entered a world ofnurses who, like me, were interested in providing the bestpossible care for their patients. The combined knowledge ofall of the nurses who were there was amazing. Everyone wasfriendly and willing to share their knowledge and best prac-tices. Being a new member, other members welcomed meand taught me all about AAACN and how I could best makeuse of my membership. It is hard to put into words the com-panionship and solidarity I felt during that first conference. Idid not want the conference to end. During the six-hourdrive home, I experienced the same exuberance one feelsafter savoring the very best hot fudge sundae. I couldn’t stoptalking about the conference and I encouraged other VAnurses to join AAACN.”

At the 2007 conference in Chicago, Sandy presented aposter on health literacy, which was part of a research proj-ect that was completed in her facility. She is also proud toreport that she is now certified in Ambulatory Care Nursingand is encouraging all her fellow VA nurses to study and takethe certification exam. Reflecting on her career, Sandy writes,“I am proud to say that I am an ambulatory care nurse. Weare the backbone of the health care arena. The importance ofambulatory care nursing should not be underestimated. Wecomfort patients, counsel them, and teach them preventivehealth measures that can lead them to healthier and happierlives. If you can reach even one person each day and helpthem improve their health status, the impact can be pro-found.”

What does the future hold for Sandy? You guessed it;Sandy is planning to return to school to earn her mastersdegree in nursing. In addition, she says, “Now that my chil-dren have graduated, I plan to reach out into the legislativearea and help society and lawmakers realize what an impor-tant role nursing plays in the health of our citizens and ournation.”

Now we travel a very long dis-tance, across the ocean to Iraq, wherewe find Carla Leeseberg, MSN/Ed,RN-BC, a member of the UnitedStates Air Force and a member ofAAACN. Carla is currently deployed inBalad, Iraq, where she works on aninpatient ward. She writes, “We takecare of the war wounded, bothAmerican and Iraqi host nationals.The work here is mostly surgical (blastinjuries, burns, gun shot wounds, amputations of both upperand lower extremities, and traumatic brain injuries to name afew). Our biggest challenge as nurses is not the physical carewe provide, but rather the cultural and language barriers thatoften complicate our ability to carry out the prescribed treat-ment plan.”

Sandy Sutton

Carla Leesberg

W W W . A A A C N . O R G 1 5

Carla received her initial baccalaureate degree in nursingfrom the University of Nebraska, and later earned a doublemasters degree in nursing and education from the Universityof Phoenix. When she is not deployed, Carla works as a nurseeducator. Her future goal is to teach undergraduate nursingstudents.

An ambulatory nurse at heart, Carla has worked for manyyears as a clinic nurse and a nurse manager for both familypractice and pediatric clinics. However, her passion is patienteducation. She explains, “Patient teaching is very rewarding.For example, I had a patient who was being non-compliantwith the prescribed treatment plan. In the beginning, Ithought the patient was deliberately not following myinstructions. However, as I worked more closely with thepatient, I began to really listen to what she was telling me. Icame to realize that the ‘non-compliance’ issue was really acultural issue that I had failed to recognize. Working collabo-ratively with my patient, I was able to implement a treatmentplan that allowed for her particular cultural beliefs. It was awin-win situation for both of us.”

Reflecting upon her membership in AAACN, Carla shareswith us her thoughts about what this has meant to her overthe years. “I have always believed that being a member ofone’s professional organization is important and my desirehas been to make a difference in my area of nursing. Havinga network of professional ambulatory nurses that I can callupon to help me, has increased my knowledge of what is

new and what is working at other sites. I don’t have to startwith an ‘empty page.’ I can use my AAACN resources to findevidence-based practice tools that really work. I can also learnabout what didn’t work and why it didn’t work, so I canavoid going down that pathway myself. It is comforting toknow that at any given time, there are colleagues that I mayhave never met, but who are willing to help answer my ques-tions and offer suggestions about any given topic withinambulatory nursing practice.”

AAACN is very proud of all our military members whohave sacrificed so much to serve their nation. Carla writes,“Serving my country as an Air Force nurse in Iraq is one of themost gratifying experiences of my life. I have proudly servedtwo tours, one in 2007 and now in 2008. I will return to theUnited States in January 2009. I am married to the most won-derful man in the world, Don A. Leeseberg Jr., who hasunselfishly taken care of our children while I am deployed,without batting an eyelash. We have five children ranging inage from 5 to 23 years old. I am looking forward to comingback home and hopefully I will see everyone at the confer-ence in Philadelphia.”

Nancy Spahr, MS, RN,C, MBA, CNSClinical Nurse Specialist

Ambulatory Care, Mayo ClinicPhoenix, AZ

Presorted StandardU.S. Postage

PAIDBellmawr, NJPermit #58

Real Nurses. Real Issues. Real Solutions.

American Academy ofAmbulatory Care Nursing

Volume 30 Number 6

AAACN is the association of professional nurses and associates who identify ambulatory care practice as essentialto the continuum of accessible, high quality, and cost-effective health care. Its mission is to advance the art andscience of ambulatory care nursing.

Viewpoint is published by theAmerican Academy of Ambulatory

Care Nursing (AAACN)

AAACN Board of DirectorsPresidentKaren Griffin, MSN, RN, CNAADeputy Associate Director for Patient CareServices/Nurse ExecutiveSouth Texas Veterans Healthcare Systems

President-ElectKitty Shulman, MSN, NCDirector, Children’s Specialty CenterSt. Luke’s Regional Medical Center

Immediate Past PresidentCharlene Williams, MBA, BSN, RNC, BCDirector, WakeMed OneCallWakeMed Health and Hospitals

SecretaryAssanatu (Sana) I. Savage, LCDR, USNSenior Nurse OfficerUnited States Naval Training Center

TreasurerTraci Haynes, MSN, RN, CENNurse Manager, Clinical ServicesMcKesson Health Solutions

DirectorsLinda Brixey, RNProgram Manager, Clinical EducationKelsey Seybold Clinic

MAJ Belinda A. Doherty, USAF, NCFlight Commander, Education and TrainingUnited States Air Force

Marianne Sherman, RN, C, MSClinical Standards Coordinator, AmbulatoryAmbulatory Nursing DirectorUniversity of Arkansas Medical Center

Executive DirectorCynthia Nowicki Hnatiuk, EdD, RN, CAE

Association Services ManagerPatricia Reichart

AAACN ViewpointEast Holly Avenue, Box 56Pitman, NJ 08071-0056Phone: (800) AMB-NURSFax: (856) 589-7463 E-mail: aaacn@ajj.com www.aaacn.org

EditorRebecca Linn Pyle, MS, RN

Editorial BoardLiz Greenberg, PhD, RNCVannesia D. Morgan-Smith, BSN, RN, BC, CNA,

MBASusan Paschke, MSN, RN, BC, NEA-BC

Managing EditorLinda Alexander

Editorial CoordinatorJoe Tonzelli

Layout DesignerBob Taylor

Education DirectorSally Russell, MN, CMSRN

Public Relations DirectorJanet D’Alesandro

Marketing DirectorTom Greene

Advertising CoordinatorHeidi Perret

Circulation ManagerRobert McIlvaine

Leading the Revolution in Building Healthier Communities

AAACN 34th Annual ConferenceMarch 26-30, 2009 • Philadelphia Marriott, Philadelphia, PA

Be sure to attend the American Academy ofAmbulatory Care Nursing (AAACN) 34th AnnualConference to discover the latest tools and educa-tion in ambulatory care and telehealth nursingpractice. Your new knowledge will help you in yourquest to continually improve patient care.

Two pre-conference sessions will be offeredThursday, March 26: “Leading the Journey toNursing Excellence and Magnet Designation” and“Preparing Nurses for Roles in Community-BasedSettings: An Innovative Education Approach.”

Concurrent sessions will run from Friday,March 27 through Sunday, March 29. New thisyear is a special leadership track covering such top-ics as service excellence, emotional intelligence,financial health, and operational excellence inambulatory care.

Calling All Telehealth NursesThere’s no shortage of telehealth nursing prac-

tice content at this year’s conference! Telehealthsessions are indicated by a telephone symbol in theregistration brochure and sessions include:

• Due Diligence: Assure Hiring the BestCandidate for Your Telehealth Position

• Implementing a Telephone Triage DecisionSupport Tool in the Primary Care Setting

• Bridging the Gap: Building HealthyCommunities One Caller at a Time

• Critical Thinking and Telephone Triage:Making the Right Choices

• WORKSHOP (2hr. 15 mins.): JugglingEfficiencies, Quality of Care, and StandardAdherence: Formulating TelehealthPerformance Metrics

Town Hall - NEW for 2009Be sure to gather with your colleagues at the

new “Town Hall” following the incomingPresident’s address on Sunday, March 29, from11:30 a.m. to 12:30 p.m. This facilitated discussionwill cover:

• What is the role of the professional nurse in theambulatory care setting?

• How are RN responsibilities differentiated fromthose of LPNs/LVNs?

• How are medical assistants appropriately uti-lized in ambulatory care?

Certification is Within Your Grasp inPhiladelphia

It has never been easier to get certified inAmbulatory Care Nursing. If you are attending thePhiladelphia conference, plan to arrive early to takeadvantage of the all-day pre-conferenceAmbulatory Care Nursing Certification ReviewCourse on Thursday, March 26. This course isinvaluable in your review and preparation to takethe exam, which will be offered by the AmericanNurses Credentialing Center at the close of theconference on Sunday, March 29. Download theexam application at www.aaacn.org/conferenceand be sure to submit it by December 19.

AAACN offers an array of certification prepara-tion resources to get you ready for the exam,including the Core Curriculum for Ambulatory CareNursing, 2nd Edition, and the Ambulatory CareNursing Review Questions, 2nd Edition, which is refer-enced to the Core Curriculum. Order your studymaterials today at www.aaacn.org.

Register online (www.aaacn.org) by February 9, 2009, to receive the Early Bird discount!

© Copyright 2008 by AAACNAJJ-1208-V-26M50