Volume 34, Number 4

JULY/AUGUST 2012

Page 3
New Toolkit for Authors
Available
Editor Kitty Shulman unveils
resources for nurse authors.
Page 4
Adding Value to Nursing
Orientation for Ambulatory
Care Nurses
Free education activity for
AAACN members!
Page 8
Telehealth Trials and
Triumphs
Are You Listening?
Page 9
AAACN News
Jan Fuchs Page 10
Member Spotlight
The Supreme Court’s recent ruling on June 28 upheld key provisions of the Patient
Protection and Affordable Care Act (PPACA). In the ruling, the Supreme Court upheld the Page 12
constitutionality of the “minimum coverage provision,” which requires citizens not cov- Health Care Reform
ered by employer- or government-sponsored insurance plans to maintain minimal essen- Controversy: Are We Being
Snookered by Sound Bites?
tial health insurance coverage or pay a penalty. People earning less than four times the
poverty line ($92,200 per year for a family of four) will receive tax credits to subsidize the Page 14
purchase of insurance. Medicaid eligibility will be expanded to include those earning up For Your Health
to 133% of the poverty line. Page 15
The PPACA will expand health care coverage to an estimated 32 million additional From Our Members
people (Abrams, Nazum, Mika, & Lawlor, 2011) and provide increased access to care Gentle Reminders
through the removal of coverage denials for pre-existing conditions and the ability for chil-
dren to stay on their parents’ policy until age 26. In addition, it encourages health pro- Coming soon!
motion and disease prevention through the removal of co-pays and deductibles for pre- The Core Curriculum for
ventive services, incorporates annual wellness visits for Medicare beneficiaries, and Ambulatory Care Nursing (3rd
supports the development of medical homes and health homes for Medicaid patients with ed.) will be released this fall.
chronic conditions. Care coordination will further be supported through the development See page 13 for details.
of community health teams, community-based collaborative care networks, and the
expanded role of Federally Qualified Health Centers (FQHC).
The PPACA incorporates the role of the nurse in the delivery of health care by focus-
ing on primary and preventive care. Nurses will be integral providers working to transition Core Curriculum for
continued on page 9
Ambulatory
Care Nursing
Third Edition
Candia Baker Laughlin, MS, RN-BC
The Official Publication of the American Academy of Ambulatory Care Nursing Editor

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© Copyright 2012 by AAACN. All rights
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2 ViewPoint JULY/AUGUST 2012
2012 Conference Highlights and
Current National Initiatives
I
It has now been a couple of months since AAACN’s
37th annual conference was held in Lake Buena Vista, FL.
I hope those who attended have returned home feeling a
stronger connection to others in similar roles, and with
renewed energy and new knowledge to face the ongoing
challenges of our ever-changing health care environ-
ment.
Our conference was a huge success. The 2012 con-
ference marks the highest conference registration in the
history of the association, with a total of 756 attendees.
Hosting the conference in the sunny, warm state of Suzi N. Wells
Florida was certainly a plus, but the tremendous success
of the conference is to be attributed to an extremely strong program and the
great work of the 2012 program planning committee.
Each year’s Program Planning Committee strives to create a conference pro-
gram that will provide attendees with professional enrichment, focusing on
ambulatory care topics that will help advance your practice and leadership skills.
The success of this year’s conference program demonstrates AAACN’s dedication
to continually improving the quality of the sessions offered. Our keynote speaker,
Barbee Bancroft, was able to make us laugh and learn, as
she discussed advances in science and technology, the
importance of collaborative care with other health care
professionals and patients, and the importance of main-
taining one’s own health.
AAACN
One of the highlights of the conference was the con- Current Initiatives
tinued theme of Health Care Reform. Beth Ann Swan,
• 2012: Highest conference
PhD, CRNP, FAAN, provided a most enriching update.
registration in history of
Several of the concurrent conference sessions also
AAACN with 756 attendees
addressed the initiatives of Health Care Reform. Other
concurrent sessions focused on clinical topics, leadership, • Development of Care
and telehealth, to name a few. The conference ended Coordination competencies
with another productive town hall meeting, facilitated by continues
Past President Traci Haynes. The audience heard from the • AAACN attended CDC
expert panel and also had the opportunity to share what
pandemic project meeting
they are doing in their institutions to respond to Health July 9, 2012
Care Reform.
• Support and future
For those who attended conference and for those
involvement of AAACN in
who perhaps did not, the Online Library
Joining Forces
(www.aaacn.org/library) is an excellent resource. Access
• AAACN member Bonnie
to the 2012 conference education sessions through the
AAACN Online Library is indefinite for full conference Richter to serve as AAACN
attendees. Your conference registration also includes rep to Joining Forces
access for two colleagues. Those of you who missed the
conference don’t have to miss the education! You can
hear the audio, see the slide presentations, and earn contact hours at your con-
venience, whatever time, day or night. Conference sessions are also available to
non-attendees. You can purchase the full conference or just those sessions that
apply to your area of practice. I hope you will access the AAACN Online Library
and realize its value.
continued on page 11
 ViewPoint Article “Wish List”
Consider sharing your ambulatory care or telehealth
nursing expertise by writing an article for ViewPoint!
New Toolkit for Download author guidelines, copy deadlines, and tips
for authors at www.aaacn.org/ViewPoint.
Authors Available ViewPoint features articles on a variety of topics of
This issue of ViewPoint marks interest to ambulatory care and telehealth nurses. The
my first official issue as the Editor of following abbreviated “wish list” includes topics mem-
AAACN’s newsletter. bers have told us they’d like to read more about, and
I am grateful to ViewPoint’s now we’re hoping you can share your experience and
knowledge with other members!
Editorial Board; the Manuscript
Review Panel; and the office staff at • Ambulatory care staffing ratios
Anthony J. Jannetti, Inc., Managing • Bariatrics
Editor Katie Brownlow and Editorial • Care coordination competencies
Coordinator Joe Tonzelli, for their • Case management
hard work in continuing to turn out • Collaboration across the continuum
Kitty Shulman a highly regarded, peer-reviewed (e.g. hospital to clinic)
publication. This group will continue to provide valued • Current practice issues
insight and expertise into the future. • Dermatology and skin topics
AAACN’s Board of Directors appointed me to this posi- • Disease management
tion in early 2012. As an AAACN Past President and board • Evidence-based practice
member for 6 years, I have a deep knowledge, passion, • Health care reform
and excitement for this organization of which I have been • Immunizations
a member for 23 years. It is both an honor and a privilege • International ambulatory care
to now serve as ViewPoint’s Editor. • Leadership in nursing education
The Editorial Board met at the Orlando AAACN Annual • Legal nurse consulting
Conference in May and discussed plans for the future. One • Magnet process for ambulatory care
of the ideas put forth was to create a Writer’s Toolkit and • Management (practice and system level)
make it accessible on the AAACN Web site • Managing change/motivating staff
(www.aaacn.org/viewpoint). We want to be helpful to • Medical home care
• Medical home model
aspiring writers. To that end, we also intend to increase the
• Metrics for ambulatory care nursing
pool of resources for potential writers by recruiting men-
• Nurse leadership
tors who are experienced and have been published. We
• Patient safety
are hard at work moving along these ideas. • Pediatrics
There are many creative and cutting-edge stories to • RN role in primary care practices/clinics
tell about the work you do in ambulatory care nursing. Not • Staff education
enough is published about nurses in this field, and we • Staffing/competencies in specialty clinics
strive to change that. • Strategic direction of leadership
We hope to connect with aspiring authors. Please visit • Telehealth laws/regulations
us online (www.aaacn.org/viewpoint), check out our • Teletriage
Manuscript Wish List, browse our newly added resources, • Travel medicine
and complete the Author Interest form. I hope to hear your
stories soon! If you or someone you know would like to write an arti-
cle on a “wish list” topic, complete the Author Interest
Kitty M. Shulman, MSN, RN-BC, is the Editor of ViewPoint. She Form at www.aaacn.org/viewpoint.
can be contacted at kittyshulman@earthlink.net

Send Us Your News Issue Deadline

ViewPoint welcomes news from AAACN members. If you have a Nov/Dec 2012 October 1, 2012
news item, photo, or success story you would like published, send it
Jan/Feb 2013 December 1, 2012
along with your name, email address, phone number, and other com-
ments/suggestions to: Katie Brownlow, AAACN ViewPoint, Managing March/April 2013 February 1, 2013
Editor, East Holly Avenue, Box 56, Pitman, NJ 08071-0056;
katie@ajj.com May/June 2013 April 1, 2013

WWW.AAACN.ORG 3
 Instructions for
Continuing Nursing
Education Contact Hours
Adding Value to Nursing
Orientation for Ambulatory
Care Nurses
Deadline for Submission: August 31, 2014
To Obtain CNE Contact Hours
1. For those wishing to obtain CNE contact
hours, you must read the article and
complete the evaluation online in the
AAACN Online Library. ViewPoint con-
tact hours are free to AAACN members.
• Visit www.aaacn.org/library and log in
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• Click ViewPoint Articles in the naviga-
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• Read the ViewPoint article of your
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2. Upon completion of the evaluation, a
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printed.
Fees
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Objectives
The purpose of this continuing nursing educa-
tion article is to increase the awareness of
maximizing opportunities for nursing orienta-
tion in nurses and other health care profes-
sionals. After studying the information pre-
sented in this article, you will be able to:
1. Discuss the value and cost-savings of the
inclusion of ambulatory care content in
nursing orientation programs.
2. Identify three ambulatory care-specific
components to create a comprehensive
new-hire nursing orientation program.
3. Describe the benefits of face-to-face
meetings with key stakeholders to gain
buy-in for content change.
The authors, editor, and education director
reported no actual or potential conflict of interest in
relation to this continuing nursing education article.
This educational activity has been co-provided
by AAACN and Anthony J. Jannetti, Inc.
AAACN is provider approved by the California
Board of Registered Nursing, provider number CEP
5366. Licensees in the state of California must retain
this certificate for four years after the CNE activity is
completed.
Anthony J. Jannetti, Inc. is accredited as a
provider of continuing nursing education by the
American Nurses Credentialing Center's
Commission on Accreditation.
This article was reviewed and formatted for con-
tact hour credit by Rosemarie Marmion, MSN, RN-
BC, NE-BC, AAACN Education Director.
Accreditation status does not imply endorsement by
the provider or ANCC of any commercial product.
4 ViewPoint JULY/AUGUST 2012
Adding Value to
Nursing Orientation for
Ambulatory Care Nurses
Maureen Sims
Gretchen Bodnar
Nurses deserve a purposeful,
meaningful orientation. New nurses
entering a health care system fre-
quently attend a hospital orientation,
followed by a general nursing-based
orientation. Nationwide Children’s
Hospital in Columbus, OH, is one of
the country’s largest not-for-profit,
freestanding pediatric health care net-
works. The hospital employs over
2,200 nurses. At Nationwide
Children’s Hospital, the acronym for
the nursing orientation is called
LAUNCH (Learning And
Understanding Nationwide Children’s
Hospital). LAUNCH, like many other
nursing orientations, includes essential
information about quality care, safety,
infection control, ethics, shared gover-
nance, assessments, emergency
response, regulatory body informa-
tion, policies, and procedures.
An orientation curriculum needs
to be continuously updated to incor-
porate evidence-based practice
changes, informatics upgrades, and
new/revised policies and procedures.
The Institute of Medicine (IOM) issued
a report, “Health Professions
Education: A Bridge to Quality” in
2003. The Quality and Safety
Education for Nurses (QSEN) was
born from that report. The QSEN
model was developed to provide
schools of nursing with curriculum
guidelines to ensure quality and safe-
ty. The six essential competencies are
patient-centered care, teamwork and
collaboration, evidence-based prac-
tice, quality improvement, safety, and
informatics (Cronenwett et al., 2007).
The success of the model sparked
interest in clinical educators in many
settings. Clinical educators know that
health care is constantly changing and
orientation must provide learners with
current information and tools applica-
FREE
Continuing Nursing
Education
ble to their practice setting. Nursing
orientation is the first opportunity to
increase awareness, establish a mind-
set of inquiry, and empower nurses
with practical tools to promote safe
behaviors (Sherwood & Barnsteiner,
2012).
Inpatient nurses valued LAUNCH,
evidenced by orientation evaluations
and a survey. However, ambulatory
care nurses identified LAUNCH as pri-
marily inpatient focused. Ambulatory
care services had steadily grown to
more than 100 specialty clinics, pedi-
atric physician offices, and urgent care
facilities. Many clinics and offices are
located off-site and one clinic is locat-
ed in a neighboring state, 120 miles
from the hospital. The number of
ambulatory care nurses attending ori-
entation also grew to about 25% of
each orientation class. The current
nursing orientation program needed
revisions to address the learning needs
of new ambulatory care nurses in a
cost-effective manner. Two separate
orientations would not be financially
feasible. Integration of ambulatory
care content would not require addi-
tional presenters, rooms, days, or
resources. Change would require
stakeholder buy-in for content
changes. The foundation for planning
and validating the orientation pro-
gram was based on information from
the literature (Brixey, 2010).
A Review of the Literature
To determine how others had
improved ambulatory care orienta-
tion, a review of the literature was
done; three articles were found.
McKeown (2003) designed an inde-
pendent program because of small
numbers of ambulatory care nurses in
orientation. McKeown described an
orientation with customized tracks for
various specialties and primary care.
Time frames were well defined for
each component. A valuable list of
 Figure 1.
Nurses’ Perceived Value of
Original Content Modules
knowledge and skills were identified
for an ambulatory nurse orientation.
Bartel (1996) focused on orientees
entering a psychological contract with
the organization. The major change to
her orientation program was the
introduction of service excellence,
customer satisfaction, empowerment,
and quality. Lengetti (2002) devel-
oped an assessment tool to be used
with primary care nurses in orienta-
tion. The tool was used to assess criti-
cal thinking and technical and inter-
personal skills.
Assessment
The methods used to assess the
LAUNCH nursing orientation program
included:
• Survey of ambulatory care nurses
who recently attended central
nursing orientation to determine
the value of each module
• Discussions with Quality
Improvement (QI) leaders to learn
about recent ambulatory care
events
An electronic survey was sent to
59 ambulatory care nurses attending
central orientation from August 2010
through April 2011. Thirty nurses
responded to the survey (51%
response rate). The survey was sent
with a message asserting the impor-
tance of response to guide change in
providing a valuable orientation to
others. The survey was sent out on
three consecutive Monday mornings.
The survey settings only allowed one-
time participant response. The survey
measured the value of each module
using a modified Likert scale (1 = no
value; 5 = great value). There was one
open-ended question, “Is there a spe-
cific topic, skill, or module that could
be added to LAUNCH to help you
function more effectively in your job?”
Ambulatory care nurses least valued
the Infection Control module content
(32%) and Medication Administration
(53%) (see Figure 1). The respondents
identified in the open-ended question
that orientation content was primarily
focused on inpatient care and did not
apply to the ambulatory care setting,
and they identified the need for edu-
cation on influenza vaccinations.
The goal of the meeting with QI
leaders was to determine problem
areas specific to ambulatory care and
identify any internal initiatives. An area
of concern was the number of “wrong
patient” vaccine errors. Another iden-
tified area of concern was patient falls,
which were more prevalent in ambu-
latory care than in inpatient areas.
The assessment findings showed
content needed to be changed in the
Infection Control and Medication
Administration modules. Influenza
vaccine and fall prevention content
needed to be developed and incorpo-
rated into LAUNCH.
Planning
Change may be difficult, but
strategies exist for managing change
(Bruce, 2009). One strategy is to have
face-to-face meetings with key stake-
holders. The benefits of personal
meetings are that they allow for spon-
taneous interaction, visualization of
non-verbal communication (to identi-
fy if stakeholders show acceptance of
information), and an opportunity to
share data. Another advantage of a
personal meeting is the opportunity
to voice concerns and hold discussion.
In addition, the need to integrate
ambulatory care objectives into the
existing orientation required presen-
ters to change presentation informa-
tion, lengthening or shortening time
frames or eliminating content. The
increasing number of ambulatory care
nurses surprised stakeholders. As a
result of the discussions, the need for
revisions was evident and they agreed
to revise presentation content.
Implementation
In May 2011, the newly designed
Medication Safety module (formerly
Medication Administration) was
implemented. The first change high-
lighted the autonomous role of the
ambulatory care nurse in medication
preparation. In the inpatient setting,
several medication safety nets are in
place to reduce errors such as a dou-
ble-check by the pharmacy, unit-dose
medications with patient labels, and
bar-coded medications. In ambulatory
care, the provider writes the order and
the nurse prepares the medication,
often from stock medications or vac-
cines. Because the ambulatory care
nurse does not have the same safety
nets as the in-patient nurse, safe med-
ication behaviors need to be imple-
mented to prevent errors.
One of the behaviors is to look at
the “Five Rights” of medication
administration from an ambulatory
care perspective. For ambulatory care
nurses, the “right time” of medication
safety for administering a vaccine isn’t
an actual time (such as 8:00 a.m.), but
is instead the correct spacing (such as
28 days). The “right medication”
includes proper labeling of each med-
ication and not just the medication
tray. Look-alike and sound-alike vac-
cines, like Tdap and Dtap, Hep A and
Hep B, or HIB are also reviewed. As a
result of numerous “wrong patient”
vaccine errors, a quality improvement
initiative process had identified
numerous siblings in one exam room
to be a “high-risk” situation. A new
policy stated that the nurse can only
take one tray of medications into the
room at a time and must check two
patient identifiers with each medica-
tion administration to ensure the
“right patient.” In ambulatory set-
tings, particularly physician office set-
tings, identification bands are not
always used. A common practice is for
the parent to identify the child by
name and birth date for the nurse.
WWW.AAACN.ORG 5
 Figure 2.
Medication Room Banner
Another safety intervention instituted
by the vaccine initiative process was
the application of an armband as a
standard practice throughout all
ambulatory care areas. No medication
or vaccine can be administered with-
out an identification band on the
child.
Another change to LAUNCH was
to introduce new nurses to strategies
to reduce medication errors. One
strategy to stop interruptions during
medication preparation and adminis-
tration is use of the “distraction-free
zone.” Banners with wording of this
reminder (see Figure 2) were placed
on the medication room door and on
medication trays. Nurses were educat-
ed to help other nurses stay focused
during all parts of the medication
process by preventing interruptions.
Another strategy used during the
Medication Safety module was to help
nurses contrast safe versus risky
behaviors when preparing and admin-
istering medications. Examples of safe
behaviors were to read the medication
label before preparing and to take the
necessary time to prepare and admin-
ister a medication or vaccine.
Examples of risky behaviors discussed
were preparing medications by habit
(selecting the white bottle with the
pink label) and hurrying because
patients are waiting. Orientees dis-
cussed how much time it takes to rec-
oncile an error versus taking the time
to give the correct medication and
dose the first time. Nurses should
never sacrifice safety for timeliness.
Another change to the
Medication Safety module was to
emphasize the positive value of
reporting errors. Nurses were encour-
6 ViewPoint JULY/AUGUST 2012
aged to be transparent and to report
an error immediately. Error reporting
helped prevent or minimize future
risks to others. Sharing information
with outside agencies such as the
Food and Drug Administration and
the Vaccine Adverse Error Reporting
System provided a mechanism for
analyzing events on a national level.
Nurses are more likely to report errors
in an environment where the focus is
directed at systems rather than indi-
viduals. Examples of how nurses are
supported at our hospital were
shared. Analysis of reported errors at
Nationwide Children’s Hospital identi-
fied that distracted nurses are more
likely to make medication errors; the
distraction-free zone banners were
provided to support nurses and to
remind all of the importance of allow-
ing nurses to maintain focus with
medications.
Storytelling was added as an edu-
cational strategy for sharing knowl-
edge, gaining appreciation of issues,
and promoting healthy behaviors
(Haigh & Hardy, 2011). Nurse orien-
tees were encouraged to share per-
sonal experiences with actual medica-
tion errors. Their stories highlighted
various ways errors can occur: incor-
rectly ordered medications, incorrect
medications or doses filled in pharma-
cy, over-reliance on the computer for
drug calculations, and overlooking
allergies or nursing errors. One nurse
cried as she shared her personal
account of a patient who received ten
times the recommended dose due to
a decimal point error. Another nurse
talked of an unfamiliar smell, which
alerted her that a wrong medication
had been sent from pharmacy.
Another nurse shared her story about
a toddler whose mother had given
him acetaminophen several times dur-
ing the night, the history of the last
dose was overlooked in the clinic and
the toddler received more acetamino-
phen, requiring him to be hospital-
ized. Storytelling elicited emotion,
provided an appreciation of how
errors affect nurses’ lives, and can be a
powerful tool to use in orientation.
A content change in the Infection
Control module was made to include
the ambulatory care environment.
New content stressed the ambulatory
care nurse’s role in protecting patients
and staff from communicable dis-
eases. It is important to know how to
screen patients, parents, and others
for recent exposures, out-of-country
travel, and fever or cough when they
arrive in the lobby. Ambulatory nurses
are responsible for maintaining a safe
environment by knowing the proper
disinfectants for cleaning exam tables
and equipment after each patient
because housekeeping staff are not
part of the ambulatory staff. Because
physician offices are usually not
equipped with negative air pressure
rooms, alternative measures for man-
aging (or isolating) patients suspected
of having chickenpox, tuberculosis,
and more were discussed. The ambu-
latory care nurse is influential in assur-
ing masks and other personal protec-
tive equipment are used by patients,
parents, providers, and other staff to
reduce exposure.
In October 2011, new content on
fall prevention improved the existing
QI module taught in LAUNCH. A
Nationwide Children’s Hospital initia-
tive, “High up, high risk,” was
designed to help staff identify patients
at risk for falls. Infant carriers on regis-
tration counters, chairs, or exam
tables were identified as high-risk situ-
ations. Another high-risk situation was
active children climbing on an exam
table or chair. The presenter helped
the ambulatory care nurses identify
their role in educating parents of fall
risks by providing anticipatory guid-
ance such as keeping infant carriers on
the floor and children who are on
high surfaces need a parent’s hand on
them to protect from falls.
Flavin, Dostaler, Simpson, Brison,
and Pickett (2006) identified a high-
risk situation for falls to be linked to
the developmental stage of the child.
Children who are learning to walk, or
those skipping, jumping, running, and
turning in circles are at a greater risk
for falls. Children carrying babies are
high-risk situations. Rowdy play
between siblings places children at
risk for falls and injuries. It is important
for the nurse to be alert when the
caregiver is distracted by other chil-
dren, talking on a cell phone, etc. The
distracted caregiver is less likely to
intervene and prevent falls, but the
 Figure 3.
Nurses’ Perceived Value of Revised
Content Modules
nurse can support the caregiver and
help provide a safe environment. The
ambulatory care nurse needs to edu-
cate registration staff on how to man-
age the lobby for high-risk situations
and when they should ask for nursing
support. Scripting is now provided to
nurses during orientation so they are
comfortable responding to caregivers
and patients in unsafe situations.
“May I sit the infant carrier on the
floor? I want the baby to be safe.
Infants who are on high surfaces are at
a high risk for falls.” Scripting is a non-
threatening way for nurses to educate
caregivers about child safety.
A new module, Influenza Vaccine
Administration, was added to
LAUNCH because patients in all areas
of the hospital and ambulatory care
received the influenza vaccine. The
presenter helped nurses determine
who is eligible for the flu vaccine and
the difference between live and inacti-
vated vaccines. Spacing rules, routes
of administration (nasal versus IM),
and age-specific requirements were
discussed. The importance of patient
and parent education is now
reviewed. Information about Vaccine
Information Sheets (VIS) and the law
requiring distribution and documen-
tation is shared.
Evaluation
A follow-up survey was sent elec-
tronically at the end of March 2012 to
17 ambulatory care nurses who
attended LAUNCH between October
2011 and March 2012. Nine ambula-
tory nurses responded (53% response
rate). The ambulatory care nurses’
value of the Infection Control module
content increased from 32% (previous
survey) to 96%. Their value of the
Medication Safety content increased
from 53% to 100% (see Figure 1). The
respondents valued the Influenza
Vaccine content at 83% and the
Quality Improvement module, includ-
ing the fall prevention content, was
valued at 88% (see Figure 3).
Conclusion
Health care is ever-changing and
orientation must reflect changes as
well. It is imperative to be attentive to
the needs of nurses in orientation and
tailor content to meet those needs. It
is critical to survey recently hired nurs-
es to identify orientation program
strengths and areas for improvement.
Encourage presenters to stay current
by reviewing evidence-based litera-
ture and new/revised policies and pro-
cedures. Quality and Safety leaders
possess valuable data and are often
involved in hospital and ambulatory
safety initiatives. Orientation is the
opportune time to introduce new
nurses to an organization’s safe prac-
tices. When requesting others to
change content, identify the best
strategies for gaining stakeholder buy-
in. Face-to-face meetings allow for
spontaneous interactions, visualization
of non-verbal communication, oppor-
tunities to share information, and time
for voicing concerns.
Nationwide Children’s Hospital’s
orientation program, LAUNCH, is
cost-effective and valued by both
inpatient and ambulatory care nurses.
Ambulatory-specific content was inte-
grated to educate ambulatory care
nurses about medication safety, infec-
tion control, fall prevention, and
influenza vaccines. One of the unfore-
seen benefits of integrating ambulato-
ry content resulted in the recognition
of ambulatory nurses and the impor-
tance of their role.
Future plans include reassessing
ambulatory care nurses’ value of nurs-
ing orientation every six months and
meeting with Quality leaders on a reg-
ular basis. A review of the literature
will be done at the time of the surveys
to glean new ideas and information.
Nursing orientation will be revised to
reflect health care changes and to
ensure quality and safety information
is provided to ambulatory care nurses.
References
Bartel, J. (1996). Revised orientation pro-
gram for ambulatory care. Nursing
Management, 27(1), 40-41.
Brixey, L. (2010). Ambulatory care nursing ori-
entation and competency assessment
guide (2nd ed., pp. 121-130). Pitman,
NJ: American Academy of Ambulatory
Care Nursing.
Bruce, S. (2009). Core curriculum for staff
development (3rd ed., p. 127).
Pensacola, FL: National Nursing Staff
Development Organization.
Cronenwett, L., Sherwood, G., Barnsteiner,
J., Disch, J., Johnson, J., Mitchell, P., …
Warren, J. (2007). Quality and safety
education for nurses. Nursing Outlook,
55(3), 122-130.
Flavin, M., Dostaler, S., Simpson, K., Brison,
R., & Pickett, W. (2006). Stages of
development and injury patterns in the
early years: A population-based analy-
sis. BMC Public Health, 18(6), 8-9.
doi:10.1186/147-2458-6-187
Haigh, C., & Hardy, P. (2011). Tell me a
story: A conceptual exploration of sto-
rytelling in healthcare education. Nurse
Education Today, 31, 409-410.
Institute of Medicine (IOM). (2003). Health
professions education: A bridge to quality.
Washington, DC: The National
Academies Press.
Lengetti, E. (2002). Competency-based ori-
entation for ambulatory care nurses: An
experience in pediatric primary care.
ViewPoint, 24(1), 11-12.
McKeown, E. (2003). New nurses. ViewPoint,
25(2), 10-12.
Sherwood, G., & Barnsteiner, J. (2012).
Quality and safety in nursing: A compe-
tency approach to improving outcomes.
Oxford, UK: John Wiley & Sons, Ltd.
Maureen Sims, MBA, BSN, RN, is a
Professional Development Nurse Specialist,
Nationwide Children’s Hospital, Columbus,
OH.
Gretchen Bodnar, MS, BSN, RN, is a
Professional/Development Nurse Specialist,
Nationwide Children’s Hospital, Columbus,
OH.
WWW.AAACN.ORG 7

Are You Listening?
In the midst of a busy day managing patients over the
phone, one patient could express a few words during the
conversation that would dramatically change the outcome
of the call. The caller may have a calm demeanor and a
nonchalant tone, but don’t make assumptions. You could
easily miss a critical situation…unless you are really listening.
Our time on the phone with patients is spent dialogu-
ing with them about common situations. We assess the
symptoms presented, identify a level of care, and then
orchestrate how that level of care will be met. If we are
using a computer-based nurse triage system or book of
protocols, we may succinctly go through the routine ques-
tions from highest to lowest acuity.
As we formulate questions, we document the patient’s
responses and determine the nature and urgency of the
call, but we must always keep listening. We must not begin
rattling off questions and making presumptions about the
caller’s replies. As we quickly document their responses to
our questions, we also must listen to the phrases that they
may simply “throw out” that originate from their own per-
ceptions of their situations. It may be in the pauses of our
conversation that callers may subtly express a crucial
descriptor. If we are not listening, we will miss it, and pos-
sibly miss getting the patient to the right level of care.
The following are based on actual patient stories and
illustrate the importance of hearing every word, not just
the responses to our questions. A life-threatening situation
could have been overlooked…if the nurse wasn’t really lis-
tening.
“It feels like my heart is beating in my stomach.”
When a patient complains about abdominal discom-
fort, we obtain information about the location, duration,
severity, associated symptoms, and so on. In this scenario,
a middle-aged man called the physician’s office reporting a
“stomachache.” He had been to the clinic to see his
provider for abdominal discomfort that he had experi-
enced for several days. The doctor diagnosed him with
reflux and he began his prescribed medications.
The patient had a monotone voice, which could reflect
that he was not experiencing acute distress. However, the
nurse noted that he had made three calls to the clinic in
one week, which was not typical for this patient. During
the call, the patient did not offer much information. Asking
him questions led to short responses. Several times during
the conversation he said, “I just have a bad stomachache.”
The level of care that seemed appropriate was to be seen
within the next 24 hours.
While the nurse was documenting the patient’s
responses, he subtly said, “It feels like my heart is beating
in my stomach.” The nurse heard this and recognized that
8 ViewPoint JULY/AUGUST 2012
his description could be a potentially life threatening situa-
tion. Indeed, it was an emergency – the patient had an
abdominal aortic aneurysm.
“I feel a ripping around my heart.”
A healthy young woman without a family history of
cardiac problems called with complaints of chest discom-
fort. The nurse mechanically asked all of the triage ques-
tions, sounding like a survey taker. Appropriately, she uti-
lized an ABC (Airway-Breathing-Circulation) approach to
rule out an emergency. She inquired, “Is it sharp, burning,
crushing, stabbing?” Those are the common chest pain
descriptors. The patient responded, “No. No. No. No.”
The nurse clicked all of the denials in the electronic health
record (EHR).
The nurse began the next series of questions. “What
makes it better? What makes it worse? Have you tried any-
thing?” Then the patient deviated from the ask-and-
answer process and said, “My chest feels like it is ripping
inside.” The nurse abruptly stopped her questions and
asked the caller to repeat what she just said. The chest pain
protocol did not list the word “ripping.” Yet the patient
was convinced that this is the right word for her pain. The
nurse was unsure of the significance of this descriptor, but
from her clinical experience, she recognized this could be
emergent.
Although the nurse was initially managing this call
with a systematic, almost rote manner, she was listening
carefully and picked up an unusual symptom description.
If the nurse had not been closely listening, she could have
missed an aortic dissection.
“My throat feels furry.”
I am often asked by triage nurses, “Should I triage a
child or their parent?” I always recommend including the
child in the triage process. If I had not a few years ago, I
may have missed an emergent situation.
A parent of a six-year-old called me and presented the
problem of throat pain. I began my usual questions. Throat
pain is quite common in school-aged children. My initial
comfort soon waned. Intuitively, I sensed that this was not
the common sore throat. I asked to speak to the child. The
mother agreed.
I asked the child questions. When he described his
throat he said, “It feels furry.” Furry? From a developmental
standpoint, what could furry mean? I had to quickly visualize
what furry means to a child – a dog’s coat, a stuffed animal’s
plush fabric, or a horse’s mane. Furry meant thick and hairy.
Was this child describing a thick sensation in his throat? This
altered my perception of what might be going on. I had to
rule out the possibility of an allergic reaction, and it was the
odd description of a “furry” throat that made me switch
gears from thinking this was a typical viral sore throat to a
potentially life-threatening allergic reaction.
In this case, the child was indeed having his first ana-
phylactic reaction to tree nuts. If I did not listen carefully
and pick up on an unusual descriptor, would I have missed
it and delayed care?
Conclusion
As registered nurses, it is not in our scope to diagnose
a patient with an abdominal aneurysm, aortic dissection,
or anaphylactic reaction. However, it is in our scope to ask
questions, document responses, and determine level of
care. It is our responsibility to listen very carefully at all
times, so when a patient uses uncommon, incongruent, or AAACN Endorses Nurse
strange words to describe common complaints, we must
recognize this and ask more questions. Coaching Document
AAACN has endorsed the first edition of Professional
Kathryn Koehne, BSN, RNC-TNP, is a Nursing Systems Nurse Coach Role: Defining Scope of Practice and
Specialist, Department of Nursing, Gundersen Lutheran Health Competencies, developed by the Professional Nurse Coach
Systems, and a Professional Educator, Telephone Triage Consulting,
Inc. She can be contacted at krkoehne@gundluth.org
Workgroup (PNCW). These competencies prepare nurses to
integrate this role within all specialty areas and settings.
Professional Nurse Coaches are equipped to implement
Affordable Care Act
health-promoting and evidence-based strategies with
continued from page 1
clients and support behavioral and lifestyle changes to
our health care delivery system from one based on “sick enhance growth, overall health, and well-being. The docu-
care” to one focused on wellness and health promotion. ment will be published in 2012. A draft of the document is
Nurses will be called upon to teach and coordinate care available online at http://www.ncchwc.org/files/DRAFT
along the health care continuum, working holistically with _2812_27_11_29_Professional_Nurse_Coach_Role_
patients and their families in various settings, and will be Defining_Scope_of_Practice_and_Competencies_.pdf
key members of the multidisciplinary care team in the
medical home model. Ambulatory nurses will play a key
role in health care delivery in these varied settings through
patient education, health promotion, care coordination, Member Carries Olympic Torch
and chronic disease management. Debra A. Toney, PhD, RN,
The American Academy of Ambulatory Care Nursing FAAN, was among 8,000 truly
(AAACN) applauds continuity of care and standardized inspirational people who were cho-
processes for all aspects of ambulatory care. AAACN stands sen to carry the Olympic Torch this
ready to help shape and develop the health care system in year. Lit in Greece, the Olympic
the United States. Flame arrived in the United
Kingdom on May 18, 2012, before
Reference setting out the next day on a 70-
Abrams, M., Nazum, R., Mika, S., & Lawlor, G. (2011). Realizing
health reform’s potential: How the Affordable Care Act will
day journey. Debra carried the
strengthen primary care and benefit patients, providers, and pay- torch on July 9. Debra is Director of
ers. Retrieved from http://www.commonwealthfund.org/ Debra A. Toney Nursing, Nevada Health Centers.
Publications/Issue-Briefs/2011/Jan/Strengthen-Primary- Congratulations, Debra!
Care.aspx

Jan Fuchs, MBA, MSN, NEA-BC, is Senior Director, Ambulatory

Care Nursing, Cleveland Clinic Health System, Cleveland, OH. She
is Chair-Elect of the AAACN Legislative Team. She can be contact-
AAACN Participating in Maximizing
ed at fuchsj@ccf.org RN Potential Workgroup
Past President Peg Mastal, PhD, MSN, RN, represented
Coming soon in AAACN at the Maximizing RN Potential Workgroup meet-
ing hosted by AARP in Washington, DC. The “charge” of
the workgroup is to improve access to efficient, quality,
Educational offerings: affordable, patient-centered care in the current and future
• Practice the Right “Rights”: A Strategy Promoting health care system, identify barriers to full utilization of reg-
Effective Immunization Delivery istered nurses who are not practicing in advanced practice
• The Medical Office Tracer: An Innovative Method roles, develop strategies for reducing these barriers, and
for Quality Improvement engage key stakeholders in implementing the strategies at
local, state, and national levels.
Plus these favorite columns: Identified barriers and strategies to overcome them will
• Telehealth Trials and Triumphs be shared with AAACN in the future. AAACN supports this
• Health Care Reform initiative as it addresses the Institute of Medicine (IOM)
• For Your Health Future of Nursing report and the issue of registered nurses
• Member Spotlight working to the full potential of their education, experience,
• From Our Members and skills.

WWW.AAACN.ORG 9

Commander Catherine M.
McNeal-Jones, Nurse Corps, United
States Navy, MBA-HCM, MSN, RN-
BC, is currently assigned as the
Senior Nurse Officer and
Department Head, Family Medicine
Medical Homeport and Clinical
Support Services, Naval Branch
Health Clinic, Kings Bay, GA.
CDR McNeal-Jones, a native of
Catherine McNeal-Jones
Houston, TX, joined the Navy
Reserves in 1988 as a Hospital Corpsman, where she pur-
sued a Bachelor of Science in Nursing from Prairie View A
& M University in Texas. After obtaining her BSN in 1992,
CDR McNeal-Jones was commissioned an Ensign in the
Navy Nurse Corps following graduation. She achieved dual
graduate degrees, Masters of Science in Nursing and
Master of Business Administration in Health Care
Management, from the University of Phoenix, AZ, in
October 2009.
Since joining the Navy in 1988, CDR McNeal-Jones has
traveled overseas twice – once during Desert Shield and
Storm on board the hospital ship USNS Mercy, and once
on a tour at Naval Hospital Yokosuka, Japan. Additional
tours of duty include Naval Branch Clinics Millington, TN,
and Naval Hospitals Jacksonville, Oak Harbor, and Camp
Lejeune. Wherever duty called, CDR McNeal-Jones enjoyed
varied nursing experiences such as medical-surgical nurs-
ing, intensive care, emergency room, and ambulatory care.
From the ambulatory care experience and patient educa-
tor role, she was able to obtain certifications as a Diabetes
Educator and Ambulatory Care Nurse.
CDR McNeal-Jones has been certified in her nursing
passion, ambulatory care nursing, since May 2006. She
enjoys the unique features of the population served from
neonates to geriatrics, active duty military to retirees and
their family members, as well as the varying levels of acu-
LVM Systems, Inc.
4262 E. Florian Avenue, Mesa, AZ 85206
www.lvmsystems.com
Corporate members receive recognition in ViewPoint, on AAACN's Web site,
and in various conference-related publications, as well as priority booth place-
ment at AAACN's Annual Conference. For more information about Corporate
Member benefits and fees, please contact Marketing Director Tom Greene at
greenet@ajj.com or 856-256-2367.
10 ViewPoint JULY/AUGUST 2012
ity – acute, chronic, and wellness. She reports there are no
dull moments in ambulatory care nursing.
CDR McNeal-Jones uses the AAACN Core Curriculum
along with the Scope and Standards of Practice for
Professional Ambulatory Care Nursing in her Senior Nurse
Officer role to ensure patient safety and Navy Medicine
guidelines. In addition, she has used these resources in
preparation for The Joint Commission accreditations over
the years.
After recently attending a NANDA International
Conference, CDR McNeal-Jones has a renewed passion for
Nursing Interventions Classification (NIC) and Nursing
Outcomes Classification (NOC). Her goal is to implement
a plan to formally return to the basics of nursing knowl-
edge using standardized classifications of nursing diag-
noses and nursing interventions to drive nursing patient
outcomes in ambulatory care.
One additional future highlight for CDR McNeal Jones
is her thought of pursuing her doctorate of nursing prac-
tice (DNP). One of her favorite quotes from James
Northcote is, “Half the things that people do not succeed
in are through fear of making the attempt.”
During her “spare” time, she enjoys catching the latest
movies with her son. This includes always seeing Marvel
movies on opening weekends, as she’s a huge Marvel fan.
While it’s not necessarily a hobby, but a way of life, she
thoroughly enjoys studying the word of God through daily
bible devotionals, readings, and church attendance. She
strives to continually learn more of God’s character, as
exampled in Christ, while garnering expectations for her
daily living.
Deborah A. Smith, RN, DNP, is an Associate Professor, Georgia
Health Sciences University, College of Nursing, Augusta, GA, and
Editor of the “Member Spotlight” column. She can be contacted at
dsmith@georgiahealth.edu
Get in the Spotlight!
In the “Member Spotlight” column, AAACN mem-
bers like you are the stars! If you would like to be fea-
tured in a future installment, please contact Deborah
Smith at dsmith@georgiahealth.edu to receive a brief
set of introductory questions. These questions can also
be found on the AAACN Web site (www.
aaacn.org/viewpoint). Please include a high-resolution
photo with your submission.
Join the ViewPoint
Manuscript Review Panel
ViewPoint is in search of manuscript reviewers. AAACN
members who have practiced in any area of ambulatory
care nursing for at least three years are eligible to join. If
you would like to volunteer your time and efforts to this
group, please send a copy of your curriculum vitae (CV) to
Managing Editor Katie R. Brownlow, ELS, at katie@ajj.com.
President’s Message cerns of this population in order to improve the lives of
continued from page 2 those who have sacrificed in their service to our country.
I am pleased to announce that Bonnie Richter, RN,
AAACN supports the professional development of
BSN, MSHA, Associate Chief Nurse for Ambulatory Care,
ambulatory care nurses through the Excellence,
Telephone Care and PACT, located in West Palm Beach, FL,
Scholarship, and Research awards that are presented at the
has been appointed to serve as AAACN’s volunteer leader
annual conference. These awards include Administrative
for Joining Forces. AAACN’s involvement in Joining Forces
Excellence, Clinical Excellence, and Scholarship or Research
is particularly important; AAACN will be positioned to bet-
Grant. Visit aaacn.org for details on how you can apply for
ter assist those members who provide quality care for our
these awards.
service members, veterans, and their families.
As one year’s conference comes to an end, planning
As you can see, your ambulatory care nursing associa-
next year’s conference begins. Please consider attending
tion is expanding our influence by advocating and promot-
AAACN’s 38th annual conference in Las Vegas, April 23-26,
ing appreciation for the specialty of ambulatory care nurs-
2013.
ing at a national level. As the year 2012 progresses, I
I’d now like to also update you regarding some of our
promise to keep you updated on other AAACN initiatives.
other current and future AAACN initiatives.
Have a very safe and enjoyable summer!
Under the leadership of Past Presidents Traci Haynes,
Beth Ann Swan, and Sheila Haas, and with the contribu- Suzanne N. Wells, MSN, RN, is Manager, Answer Line, St. Louis
tions of many members, AAACN will complete our work in Children’s Hospital, St. Louis, MO. She can be contacted at
the development of care coordination competencies for snw4713@bjc.org
the registered nurse. This project will promote the value of
the registered nurse as a key member of the heath care
team in providing patient centered care across the health
care continuum.
Member-Get-a-Member
AAACN has recently been collaborating with the Campaign Underway
Centers for Disease Control and Prevention (CDC) in their
nurse triage line pandemic project. In collaboration with
the CDC, to move to a state of “readiness” in preparation
for the next pandemic, AAACN is investigating the feasibil-
ity of a registry of nurse triage call centers. In the event of
a high-level pandemic, these call centers will utilize guide-
lines consistent with the CDC for the distribution of antivi-
rals. Through the coordinated efforts of the CDC, AAACN,
nurse triage lines, and other national health related associ-
ations, we will promote social distancing, decrease the
surge in our emergency departments and primary practice The annual AAACN Member-Get-a-Member cam-
settings, and decrease the spread of disease. paign has begun. When you recruit your colleagues
In early July, I attended a nurse triage line planning through December 31, 2012, you will be entered into a
meeting at the CDC, along with Past President Linda Brixey
monthly drawing to win a $50 AAACN gift certificate.*
and two volunteer leaders, Carol Rutenberg and Lynn
Smith-Cronin. I will keep you updated on the progress of At the end of the campaign, three grand prizes will be
this project. Although we may not have a high-level pan- awarded:
demic for years to come, moving to a state of “readiness” • Renewal of one membership for 2 years (chosen via
through the establishment of a registry, AAACN will be bet- a drawing of all recruiters).
ter positioned to swiftly support our members during a • $100 AAACN certificate (given to all recruiters who
time when, as those who provide telephone triage know, recruit 3 or more members).
planning, communication with the community, and proto- • Complimentary registration to the following year’s
cols can change day to day. conference (awarded to the member who recruits
Another AAACN future initiative to tell you about is the most members).
Joining Forces. First Lady Michelle Obama and Second Download a membership application at
Lady Dr. Jill Biden have mobilized all sectors of the commu- www.aaacn.org/getamember, write your name in the
nity through a comprehensive national initiative, Joining
"Who referred you to AAACN?" section at the bottom,
Forces, that will give service members, veterans, and their
families the support they so deserve, specifically in the and share copies with your colleagues, letting them
areas of wellness, education, and employment. Through know why you belong to AAACN. Thanks for helping us
AAACN’s support and future involvement in Joining Forces, grow the organization and bring attention to the spe-
we, along with others in the profession of nursing, will be cialty of ambulatory care!
prepared to recognize the unique health and wellness con- *AAACN certificates may be redeemed for conference registration
fees, webinars, or to purchase products and resources.

WWW.AAACN.ORG 11
 View health care reform resources online at:
www.aaacn.org/HCReform

Controversy: Are We Being their homes versus moving to nursing homes or assisted
living. Universal health care offers the option of home
Snookered by Sound Bites? health care aids three times per week. This certainly seems
to be a high-quality option as well as a cost-effective one.
As I write this, my husband and I are returning from a
As we cycled through the countryside and cities, we did
bike and barge tour in the Netherlands. It was an eye-
not see nursing homes or assisted living organizations. We
opening trip. We were expecting to be the oldest bikers on
also talked with someone who had lived in the U.S. for
our tour and in the Netherlands. Much to our surprise,
many years and paid three times as much for health insur-
there were several couples on the tour who were in their
ance with less care provided than is now available under
late 70s, and even more surprising were the numbers of
universal health care in the Netherlands.
older residents of the Netherlands who used bikes as a pri-
The Europeans we spoke with were quite aware of the
mary means of transportation. Bikes are everywhere:
political forces in the U.S. that are fostering the controver-
moms cycle with their children on the bike or peddling
sy over our incremental approach to health care reform in
alongside; all cyclists have panniers; they are used for mar-
the Patient Protection and Affordable Care Act (PPACA). In
keting, going to and from workplaces, and hauling every-
industrialized Europe, fee-for-service methodology is not
thing imaginable. This was true in the cities as well as the
used; there is less of a legalistic overlay and health care is a
countryside. Using bikes as an alternative means of trans-
right, not a privilege. So every citizen has the same health
port contributed to less air pollution and noise as well as an
care benefits. In the U.S., health care is seen as a commod-
apparently healthy population.
ity available to those who can pay for it, usually through
More startling in the Netherlands was the visible
employer plans or for those who are impoverished, a vet-
absence of obesity in residents young and old. There were
eran, or elderly. Fee-for-service is a driver for increased vis-
three obvious reasons: 1) exercise (walking, biking, stair
its and tests as well as cost, plus it promotes less focus on
climbing), 2) diets with abundant fresh fruits and veggies
quality. First and foremost in the U.S., opposition to univer-
and fewer fast food and processed food options, and 3) a
sal health care comes from health insurance companies
general focus on health. Another observation was the
with lobbyists. In Europe, where the Bismarck model pro-
absence of homeless, destitute, and impoverished persons
vides the framework for health insurance support for uni-
and areas even in cities. There were no food deserts (areas
versal health care in countries such as Germany and
where healthy food markets are rare) nor were there large
Switzerland, overhead and profit by insurance companies
supermarkets. In the city as well as the villages, street mar-
is capped (Frontline, 2008). Currently in the U.S., health
kets and small stores offering fresh produce, dairy prod-
care insurance companies can take as much as 20% (or 20
ucts, meats, and staples were readily available. Bakeries
cents) or more out of every health insurance dollar for
offering whole grain breads and cereals were common.
overhead and profit, while Medicare overhead (and no
These observations led us to talk with residents and
profit) is closer to 3% (Cohen, 2009). PPACA will cap this
international visitors on our tour as well as hosts in our bed
at 15% in large group markets (Davis et al., 2010). Is it any
and breakfast accommodations. We found those who live
surprise that health care in the U.S. consumes 17.4% of our
in countries with some form of universal health care were
gross domestic product (GDP) given just insurance over-
more than satisfied with care access, quality, and cost. They
head and profit? In industrialized Europe, health care costs
were also well aware of the current health care reform con-
range from 8.5% to 12% of GDP (Squires, 2012). Not only
troversy in the United States. They were genuinely per-
is this costly for us as citizens, but it also makes the price of
plexed by U.S. sound bites and stories about the dangers
our products less competitive on the world market.
of “big government” controlling health care and had ques-
While the U.S. has the most expensive health care, it is
tions such as, “How can you let insurance companies con-
also very ineffective and Americans have limited access to
trol health care without regulation?” They had a depth of
care. The World Health Organization (WHO) ranks the U.S.
understanding of our health care challenges that many in
as #37 in the world in health care (Murray & Frenk, 2010).
the U.S. do not have. Given the fact that many survive on
Much of this ranking is based on poor access to care in the
a diet of sound bites, it is a challenge in the U.S. to find in-
U.S. Outcomes of care in the U.S. are not nearly as good as
depth analysis of issues that do not include bias that is
those in other industrialized countries (Shea, Holmgren,
often not clearly acknowledged. Our European acquain-
Osborn, & Schoen, 2007), where they have been using
tances offered examples of excellent holistic care when sur-
research evidence to standardize care. In the U.S., it takes
gery was needed. Such care included follow-up home vis-
an average of 17 years to put evidence into practice and
its by professionals. They also talked about care for senior
we have a high incidence of errors (Institute of Medicine,
citizens where every effort is made to allow them to stay in
2000). In addition, in the U.S., care is most often provided

12 ViewPoint JULY/AUGUST 2012

for acute illnesses because we have insurance systems that Zycher, B. (2011). Comparative effectiveness reviews: Quantitative
are focused on sick or acute care versus preventative care. analysis of research and development investment effects. Retrieved
from http:// www.pacificresearch.org/docLib/20110715_
Again, the PPACA has many provisions for health promo- Zycher_CER_F.pdf
tion, wellness, and prevention. Many of these provisions
were modeled on those in place in industrialized Europe. In Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of
past columns, we discussed the wellness plan available to Nursing, Loyola University of Chicago, Chicago, IL. She can be con-
all Medicare patients under the PPACA, also the screenings tacted at shaas@luc.edu
for early detection of disease in children, women, and men
that are free. Also, included in PPACA provisions are initia-
tives for early detection and intervention for chronic dis-
eases such as diabetes, heart disease, and hypertension. Post Your Health Care Reform
There are other powerful stakeholders who stand to Comments and Questions
lose or need to change practice with implementation of
PPACA provisions and thus are not supporters; pharmaceu- Member Jan Fuchs, MBA, MSN, NEA-BC, moni-
tical companies are an example. Today, such companies do tors posts in the online Health Care Reform Forum
direct marketing to consumers to create demand for drugs (http://www.aaacn.org/hcrforum). Jan completed
that may or may not be most effective for acute or chron- her Health Care MBA and is fascinated by health
ic conditions and may also have very severe side effects. care policy. She has been actively involved in legis-
The cost of such drugs also drives up the cost of care if lation in Ohio and is part of a group working to
physicians succumb to patient pressure to prescribe. The remove barriers to health care delivery. Members
PPACA has provisions that demand comparative effective- are encouraged to post their comments and ques-
ness analysis for drugs and treatments, so only the most tions via the Forum. The Forum is another way
effective are those that are prescribed (Zycher, 2011). AAACN is providing networking opportunities to
The PPACA Insurance Mandate discussed in the assist you with implementing the required changes
May/June ViewPoint “Health Care Reform” column (Haas, related to health care reform.
2012) is a good example of the use of sound bites to sway
Visit the online forum today!
public opinion on the value of the PPACA. The Insurance
http://www.aaacn.org/hcrforum
Mandate would financially affect only 3% of U.S. citizens,
but offers potential for universal coverage for all. Opposition
to the Mandate has been brought to the U.S. Supreme
Court, largely as a means of maintaining the status quo or Advance your practice
business as usual. Will “overturn” of the Mandate or the
entire PPACA and health care reform in the U.S. come about Prepare for certification
as a result of sound bites? In the next column, we will dis- Improve patient care
cuss the Supreme Court’s decision that was made in June.
Coming this fall:
References The new Core Curriculum for Ambulatory Care Nursing,
Cohen, D. (2009, March 29). Why are health insurance companies afraid
of competition? Retrieved from http://www.huffington Third Edition, Candia Baker Laughlin, MS, RN-BC, Editor
post.com/donald-cohen/why-are-health-insurance_b_179317.html A comprehensive administrative and clinical guide
Davis, K., Guterman, S., Collins, S.R., Stremikis, K., Rustgi, S., & to ambulatory care
Nuzum, R. (2010). Starting on the path to a high performance
health system: Analysis of the payment and system reform provi-
sions in the Patient Protection and Affordable Care Act of 2010. Updated cover-to-cover with:
Retrieved from http://www.commonwealthfund.org/ Core Curriculum for
Publications/Fund-Reports/2010/Sep/Analysis-of-the-Payment- Ambulatory • Content from the new ANCC Test
and-System-Reform-Provisions.aspx
Frontline. (2008). Sick around the world: Can the U.S. learn anything
Care Nursing
Third Edition
Content Outline for the
Candia Baker Laughlin, MS, RN-BC Ambulatory Care Nursing
from the rest of the world about how to run a health care system? Editor

Certification Exam
Retrieved from http://www.pbs.org/wgbh/pages/frontline/
sickaroundtheworld/ • Expanded focus on clinical care
Institute of Medicine. (2000). To err is human: Building a safer health and telehealth practice
system. Washington, DC: National Academies Press. • New chapters include
Murray, C., & Frenk, J. (2010). Ranking 37th – Measuring the per- perioperative care,
formance of the U.S. health care system [Electronic version]. The
complementary and alternative
New England Journal of Medicine, 362, 98-99. Retrieved from
http://www.nejm.org/doi/full/10.1056/NEJMp0910064 Earn 31.5 therapies, and transition care
Shea, K.K., Holmgren, A.L., Osborn, R., & Schoen, C. (2007). Health contact hours!
system performance in selected nations: A chartpack. Retrieved
from http://www.commonwealthfund.org/usr_doc/Shea_hltsys Watch for more information in future
performanceselectednations_chartpack.pdf issues of the enews, ViewPoint, and
in your email.
Squires, D. (2012). Explaining high health care spending in the United
States: An international comparison of supply, utilization, prices, Phone: 800-AMB-NURS ❘ E-mail: aaacn@ajj.com ❘ www.aaacn.org
and quality. Retrieved from http://www.commonwealth
fund.org/Publications/Issue-Briefs/2012/May/High-Health-
Care-Spending.aspx
WWW.AAACN.ORG 13
 • Interested in helping your patients to find tested home
remedies that may help them assess the problems they
are encountering and empower them to make wise
health care choices? Check out these new books:
• Mayo Clinic Book of Home Remedies
http://store.mayoclinic.com/products/book
Details.cfm?mpid=62
• The Athlete’s Book of Home Remedies
http://www.barnesandnoble.com/w/the-athletes-
book-of-home-remedies-jordan-metzl-md/
1030079661
• July is Ultraviolet Safety Month, which is the perfect
time to remind your patients about summer sun sur-
vival. Visit http://www.fda.gov/downloads/For
Consumers/ConsumerUpdates/UCM143731.pdf to
read the U.S. Food and Drug Administration’s “Sun
Safety: Save Your Skin” handout.
• August is Immunization Awareness Month, and cer-
tainly immunization efforts for children are ramped up
We took everything
in anticipation of a new school year. But while immu-
nizing children, think also of their parents who may
you need for your job
not have up-to-date immunizations. Download a flyer
from the Centers for Disease Control and Prevention
search and put
( h t t p : / / w w w. c d c . g o v / v a c c i n e s / s c h e d u l e s /
downloads/adult/adult-schedule.pdf) to post in your
it all in one place.
exam rooms for all parents to see. Remember, a
chance to wait is a chance to immunize! Welcome to the AAACN Career Center – your
• Heat-related injuries can cause disability and even leading resource for an ideal position or
death if not readily managed. For an overview of how
to prevent heat-related illnesses, refer to this guide from effective recruitment. Job seekers can:
the Centers for Disease Control and Prevention: t Find the right nursing jobs. Quicker.
http://www.bt.cdc.gov/disasters/extremeheat/heat- t Get job alerts
tips.asp
t Receive targeted e-mails, e-newsletter,
Carol Ann Attwood, MLS, AHIP, MPH, RN,C, is a Medical and career advice.
Librarian, Patient Health and Education Library, Mayo Clinic
Arizona, Scottsdale, AZ, and a ViewPoint Editorial Board member. And if you’re hiring, there’s something for
She can be contacted at attwood.carol@mayo.edu you too. Because we’re connected to other
disciplines’ career centers, your job posting is
seen by more people every day.
White Paper Explains Nurses’
Value in Care Coordination
The American Nurses Association (ANA) released a
white paper entitled The Value of Nursing Care
Coordination. The White Paper was initiated to highlight
both the qualitative and quantitative accomplishments of
registered nurses in care coordination. Its focus is on recent
reports and studies that have documented results involving Connect today!
registered nurses in care coordination. Visit http:// www.healthecareers.com/AAACN
www.healthecareers.com/AAACN
www.nursingworld.org/carecoordinationwhitepaper to read 



t

JOGP!IFBMUIFDBSFFSTDPN




t

JOGP!IFBMUIFDBSFFSTDPN
the paper. AAACN is an Organizational Affiliate of ANA.

14 ViewPoint JULY/AUGUST 2012

 Conference Education Continues
Poster presentations from the May conference are now
posted on the Web site (www.aaacn.org/library). Members
can learn from clinical, management, professional develop-
ment, and research posters displayed by colleagues at the
conference by logging into the AAACN Online Library.
Audio recordings and slides from the Leadership,
Patient Education, Pediatric, Staff Education, Veterans
Affairs, and Telehealth Special Interest Group (SIG) sessions
from the recent conference are also being made available
for the first time, for free, in the Online Library. If you have
an interest in any of these areas, take advantage of this
opportunity to listen and learn from the topics discussed at
each of these SIG sessions.
Briefings presented by military leaders at the 2-day Pre-
Conference are now posted on the Tri-Service SIG page.
Nurses in all branches of the military who were unable to
attend the Pre-Conference are invited to view the briefs.
Contact hours are not available from these sessions.
The presentations are being offered in the AAACN Online
Library to enhance your education and leadership skills.
AAACN Marketing Opportunities
Advertise with AAACN and reach more than 2,000
nurse managers and supervisors, nurse administrators
and directors, staff nurses, educators, consultants, NPs,
and researchers – the ideal audience for your sales and
marketing message!
Marketing opportunities include:
• Exhibiting at the AAACN Annual Conference
• Corporate sponsorships
• Premium advertising
• ViewPoint, the AAACN official newsletter
• AAACN Web site
• AAACN monthly Enewsletter
• Online Library
• Conference program book
For more information, contact Marketing Director Tom
Greene at greenet@ajj.com or 856-256-2367.
Interested in Writing
for ?
Consider sharing your ambulatory
care or telehealth nursing expertise
by writing an article for ViewPoint!
Download author guidelines, copy
deadlines, and tips for authors at
www.aaacn.org/ViewPoint
See page 3 for a list of suggested topics.
Gentle Reminders
The elderly man hobbled into my office using his walk-
er, his loving wife right beside him. He had the sweetest
smile…as innocent as a child’s. When they were both seat-
ed, I took his vital signs asked him certain questions regard-
ing his health. The final question was, “Do you have any
pain?” He continued to smile and quietly answered, “No,
Nurse Donna. I am fine.”
My nursing intuition told me otherwise. His wife spoke
up and said that he did in fact have pain. His back had
been hurting him “for a while now, and he didn’t fall or
anything.” I explained the pain scale, and then asked him
the severity of his pain. He softly replied “A one, maybe a
two.” I proceeded to ask him questions such as location, if
there was any radiation, etc. He answered quietly every
time. He told me he didn’t like to complain, “especially
when there are so many people worse off than me.” I
assured him that he could freely express his feelings, and
he simply replied, “Thanks, but I’m okay.”
He saw the physician next, who ordered an MRI of his
back. The MRI showed multiple lesions that the radiologist
felt certain was metastasis. He was admitted to the hospi-
tal Oncology Unit for a few days where they did a biopsy
and released him home pending the pathology report,
which would determine the next course of action.
I called him at home once he was discharged, and he
again said, “I am still in some pain, but it is better than it was.
The pain medicine helps. Aren’t I lucky to have some relief?”
I told him I would see him at his upcoming office visit,
and to call in the meantime if he needed anything at all. “I
will, and thank you so very much for calling,” he replied.
As I hung up the phone I realized that this sweet, inno-
cent man had reminded me of a few of the most important
lessons I had learned many years ago in nursing school:
• Sometimes a patient’s body language speaks louder
than his or her words.
• Take the time to ask questions, and really listen to the
patient’s answers.
And, most important of all,
• Never forget to let the patient know how much you
care.
Donna M. Carroll, BSN, RN-BC, is Primary Care Nurse, NFSG
Veterans Health System, The Villages VA Outpatient Clinic, The
Villages, FL. She can be contacted at donna.carroll@va.gov
Call for Member Stories
In the “From Our Members” column, we welcome short
submissions and photos from members who wish to
share their nursing stories and experiences, practice
innovations, and lessons learned. Submissions should be
no more than 600 words and can be emailed to
katie@ajj.com for consideration.
WWW.AAACN.ORG 15
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Volume 34, Number 4

ViewPoint is published by the

American Academy of Ambulatory
Care Nursing (AAACN)
AAACN Board of Directors
President
Suzanne (Suzi) N. Wells, MSN, RN
President-Elect
Susan M. Paschke, MSN, RN-BC, NEA-BC
Immediate Past President
Linda Brixey, RN
Director/Secretary
Mary Vinson, DNP, RN-BC, CMPE
Director/Treasurer
Col. Carol Andrews, MS, RN-C, NE-BC, CCP
Directors
Judy Dawson-Jones, MPH, BSN, RN
Nancy May, MSN, RN-BC
Barbara Pacca, BSN, RN, CPN AAACN is a welcoming, unifying community for registered nurses in all ambulatory care settings.
Executive Director Our mission is to advance the art and science of ambulatory care nursing.
Cynthia Nowicki Hnatiuk, EdD, RN, CAE
Director, Association Services
Patricia Reichart
AAACN ViewPoint
www.aaacn.org
Editor
Kitty M. Shulman, MSN, RN-BC
Editorial Board
Carol Ann Attwood, MLS, AHIP, MPH, RN,C
Patricia (Tricia) Chambers, BHScN, DC, RN
Virginia Forbes, MSN, RN, NE-C, BC
Liz Greenberg, PhD, RN-BC, C-TNP
Patricia L. Jensen, MSN, RN
Laura Morano, RN, CPN, MA
Ginger H. Whitlock, RN, MSN, CNA
Manuscript Review Panel
Ramona Anest, MSN, RNC-TNP, CNE
Deanna Blanchard, MSN, RN
2013 Conference Keynote Selected
Donna M. Carroll, BSN, PN-C Virginia R. Beeson, MSN, NEA-BC, has been selected as the
Jennifer Mills, RNC, CNS-BC
Vannesia D. Morgan-Smith, MGA, RN, NE-BC
Keynote speaker for the 2013 conference, April 23-26, 2013, at
Becky Pyle, MS, RN the Las Vegas Hotel and Casino in Las Vegas, NV. “Ginny” will
Janice S. Tuxbury, DNP, FNP-BC
present Why Courage? The session will explore what is meant by
Managing Editor
Katie R. Brownlow, ELS courage as a leadership skill and why it is so important in today’s
Editorial Coordinator rapidly changing world. Ginny will provide suggestions on how
Joe Tonzelli
to become a more courageous leader.
Layout Designer
Bob Taylor
Ginny Beeson is a nurse executive, consultant, and educator with over 30
Education Director years of experience in nursing. She was a Navy nurse for most of her career, med-
Rosemarie Marmion, MSN, RN-BC, NE-BC surg being her clinical specialty. She taught leadership and management for six
Marketing Director years, and held numerous nurse executive jobs, including two Chief Nurse posi-
Tom Greene
tions, and an assignment as the Deputy Director of the Navy Nurse Corps, direct-
ing policy and programs for Navy nurses worldwide. She retired from the Navy in
June 2003 as the Chief Nurse Executive at The National Naval Medical Center in
Bethesda, MD. She now teaches and consults on leadership issues at hospitals,
www.facebook.com/AAACN health systems, and universities around the country.

@AmbCareNursing

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