I

AMBULATORY BEST PRACTICES

ChallengingMisperceptions About

ASC Nursing: My Story

The AORN Journal

the column coordin

530 j AORN Journal

SARAH LOGUE, BSN, RN, CNOR, LHCRM

f you had asked me 10 years ago whether peri-

operative ambulatory nursing would be my

career path, I would have laughed. I was a hard-

working hospital perioperative nurse who circu-

lated, scrubbed, and took call frequently, and I

could not imagine how outpatient surgeries could

compare with what I viewed as the life-changing

and often life-saving procedures we performed

every day in the hospital setting. At that time, I

viewed outpatient surgeries as being mostly simple

procedures, such as tonsillectomies and cataracts.

My perception then was that “real” OR nursing

took place only in the hospital setting.

Although the demand for ambulatory services

continues to increase in the United States, periop-

erative nurses may have incorrect perceptions about

ambulatory care nursing. What follows is my ex-

perience in overcoming my perceptions about

ambulatory care. The purpose of sharing my story

is to help other perioperative nurses expand their

outlook on ambulatory surgery center (ASCs) and

the role of nurses in the outpatient setting.

BACKGROUND

After my husband underwent open heart surgery,

our lives changed forever, and there were new

personal matters to balance with professional ob-

ligations. Part of that change required us to move

is seeking contributors for the Ambulator

ator, Debra Garton, by sending topic id

� November 2014 Vol 100 No 5

from one area of the country to another. I began a

new OR position in a hospital that had recruited

me. This new hospital setting, however, did not

fulfill my understanding and expectations of the

job. In particular, I did not have the support that

I had known in my previous nursing positions.

Instead of being valued for my previous clinical

experience, I had to start over and prove myself

to a new set of physicians, anesthesia professionals,

and fellow OR personnel. In addition, the inter-

personal culture of the hospital OR was not ideal

(eg, lack of support for a team concept in the OR,

lack of valuing each team member as equally im-

portant). I felt pressured to circulate and scrub pro-

cedures that my colleagues did not want as well as to

take more on-call shifts than others did. During

the course of this experience I questioned what I

believed about being a perioperative nurse. I real-

ized that I needed to change not only my outlook

on nursing but also my professional situation.

NEW BEGINNINGS, NEW PERCEPTIONS

While I was searching for a solution to my job

situation, two surgeons who owned an ambulatory

plastic surgery facility offered me the opportunity

to broaden my OR skills in a unique waydby

managing their ASC. These surgeons were in the

process of bringing on two more board-certified

y Best Practices column. Interested authors can contact

eas to journalcolumns@aorn.org.

http://dx.doi.org/10.1016/j.aorn.2014.08.005

� AORN, Inc, 2014

AMBULATORY BEST PRACTICES www.aornjournal.org

plastic surgeons, to allow them to meet their goals

of increasing the size of the center’s patient base

while remaining a single-specialty, physician-

owned facility. I accepted the position because

the surgeons convinced me that they valued the

entire team and that teamwork was how they

wanted to care for patients.

Very quickly my new role began to challenge

my perceptions of what it means to be an ASC

nurse. Instead of having a primary nursing focus,

as manager of an ASC, I assumed several roles,

some that I had never performed before in the

clinical setting. In addition to being the RN circu-

lator for procedures, at other times, I was the pre-

operative or postoperative nurse. I scheduled

Transitioning from the hospital setting to anambulatory setting in which there are no otherdepartments, resources, or mentors to helpresolve an issue was an eye-opening experi-ence for me.

personnel in the ASC

and in the physicians’

clinical practices. I

was a safety officer,

a quality assurance/

process improvement

specialist, licensed

risk manager, and an

infection prevention

nurse. I created policies and procedures, and was

the go-to person for anything these documents

did not address. In addition, I came into the

physicians’ clinics on weekends and after hours

when they needed to see patients.

This ASC was not part of a large management

company or owned by physicians in multiple spe-

cialties. Generally, small physician-owned ASCs

have more financial and operational challenges

in terms of providing patient care and remaining

solvent, unless the center performs eye, orthopedic,

or endoscopic surgery (ie, these procedures have

a higher volume and easier turnover, which trans-

lates to higher revenue per OR minute). Com-

paratively, larger centers attached to corporations

or hospitals have greater resources. For example,

when setting up a new service or when working

on a necessary policy change, staff members at

these facilities have consultants or mentors who

can guide them through the process. This is not to

imply that corporate-owned ASCs do not expe-

rience some of the same operational challenges

and issues that small, single-specialty, physician-

owned facilities encounter; however, transition-

ing from the hospital setting to an ambulatory

setting in which there are no other departments,

resources, or mentors to help resolve an issue

was an eye-opening experience for me.

Another misperception of the ambulatory setting

is that there is little structure compared with the

main OR setting. However, the opposite is true,

in particular with staffing plans and on-call struc-

tures. My staff members and I are not required

to work long days and then mandatory on-call

shifts. It is a rare thing for staff members to work

a weekend shift, and

I have developed a

call tree for instances

when a physician

needs to come into

the clinic on a week-

end. I have instituted

several flexible sched-

ules to accommodate

different staff member needs in the ASC and the

two clinical offices. I work diligently to cover all

of the responsibilities for various areas because I

appreciate that the physicians never complain

when I am out of the office. There have been

some weeks that I have worked 48 to 50 hours,

but these hours do not compare with the some-

times 60 to 70 hours that I often worked in the

hospital setting.

Culturally, the ASC promotes teamwork and

supportive interpersonal dynamics. The physi-

cians respected me from the outset, and I con-

tinue to feel valued for my input. Staff members

receive generous benefits that do not automati-

cally expire if unused. There are bonuses, and

the benefit of working in a plastics facility with

a medical spa. The facility has very little staff

turnover, and I work with a terrific team. In

addition, working at an ASC has helped stabi-

lize my work/life balance.

AORN Journal j 531

November 2014 Vol 100 No 5 AMBULATORY BEST PRACTICES

PROFESSIONAL GROWTH

Developing a new outlook about what it means to

be an ambulatory perioperative nurse has allowed

me to grow professionally. I have learned so much

by working in an ASC. I have performed quality

improvement studies by using unique approaches

to address an issue (eg, being solely responsible

for determining a need and for devising and im-

plementing a strategy to meet that need; identi-

fying and giving gift certificates to RNs whose

patients return their satisfaction surveys at their

In struggling to manage several positions,please physicians and patients, and maintain ahappy and well-adjusted staff, I have learnedhow to be more proactive as a team memberand cultivate leadership skills.

first postoperative

visit). Quality assur-

ance for my facility

involves the use of the

Accreditation Associa-

tion for Ambulatory

Health Care model.

We have a quality

management commit-

tee composed of the three physicians, an anesthesia

representative, a scrub technician, one of my med-

ical records staff, and me. There is a governing

body to which members of the quality manage-

ment committee report, and, as the licensed risk

manager for my facility, I complete quarterly in-

cident reports, provide the information to the com-

mittee without identifying the persons involved,

and discuss how we can prevent future incidents

and improve patient care. I use a tool to track

negative outcomes for patients (eg, pulmonary

embolisms), and we develop interventions to

reduce this outcome. I report this information

to both the quality management committee and

the ASC’s governing body. As the licensed risk

manager, I must file an annual report with the

state, and I am often the driver behind the

everyday question, “What can we do better?”

As a result of working in an ASC, I have learned

to handle all kinds of situations and have called

on strengths that I did not realize I possessed. It

has been an amazing, sometimes frustrating, and

always educational eight years. During this time, I

have acquired a different opinion of perioperative

532 j AORN Journal

peers who work in free-standing ASCs. In strug-

gling to manage several positions, please physi-

cians and patients, and maintain a happy and

well-adjusted staff, I have learned how to be

more proactive as a team member and cultivate

leadership skills that I never would have had the

opportunity to develop in my previous nursing

positions.

In my ASC, I also had the privilege of watch-

ing two young physicians become successful

surgeons and broaden their skills and take

these skills to other

counties. Watching

the surgeons build

their practices, seeing

their families grow,

knowing how they

care for their patients,

and knowing that the

staff members and I

are part of their practicedall of this has made

me proud to be in health care. My team and I

are proud of our ASC’s ability to provide care

and to turnover rooms quickly; and our patient

satisfaction surveys support our success.

THE CHANGING FACE OF AMBULATORYCARE

According to the executive director of the Texas

Ambulatory Surgery Center Society, in 2013, there

were 5,260 ASCs in the United States1; at the same

time, the American Hospital Association stated that

there were 5,724 hospitals in the United States.2

Ambulatory surgery centers in Texas may soon

outnumber hospitals, and, in some states, they

already do.1 According to the Ambulatory Surgery

Center Association, 65% of ASCs are physician

owned, and these facilities offer patients a model of

care that “allows patients to deal directly with their

health care provider in a more patient-centered

and personalized setting.”1 Strong physician in-

volvement is known to promote “direct knowledge

of patient care, reduction in frustrating wait times

for patients and better patient-doctor interaction.”3

AMBULATORY BEST PRACTICES www.aornjournal.org

With changes in health care funding and ad-

vances in technology, development of new ASCs

will continue because of the cost advantages they

provide. As a result, more perioperative per-

sonnel will be needed in the ASC setting. These

personnel must be flexible, well-rounded clinicians.

Staff members must be able to float from area to

area. A staff person may work the preoperative

area at the start of the day, provide circulator lunch

relief, and then provide care in the postanesthesia

care unit in the afternoon. He or she also may need

to scrub. In addition, personnel must be willing

to clean patient care equipment and wipe down

patient monitoring equipment. Being well rounded

entails ASC personnel being able to interact posi-

tively on a daily basis with the public. As a nurse

in a main OR setting, I rarely came in contact with

family members. In an ASC, however, personnel

may be admitting or discharging patients and are

responsible for updating family members in per-

son during a procedure, providing postoperative

instructions, and performing any number of other

tasks that require contact with patients’ family

members. Most perioperative health care providers

are focused on discovering the right mix of pa-

tients and procedures that can be performed

safely outside of the traditional hospital OR.

Ambulatory surgery centers are uniquely poised

to direct how quality surgical patient care is

provided in the years to come.

CONCLUSION

I have networked with leaders from other ASCs

and listened to the unique approaches that they

have devised to resolve issues and improve their

patient care. I want to be able to share in that in-

formation and see it showcased to professionals in

similar situations. Managers rely on networking,

using the Internet, and marshaling resources to

solve whatever problems arise. Some of the in-

formation found can be misleading or incorrect,

so managers have to learn from whom and where

to solicit help. This is one of the reasons it is so

valuable that AORN is becoming more of a pres-

ence in the ASC arena. AORN has the resources

and the respect of nurses, physicians, industry

manufacturers, and vendors to build a strong

program for ASCs of all types. The potential is

there to provide services that are not cost prohibi-

tive and provide standards for quality care. AORN

partnering with already existing ambulatory surgery

organizations is a win/win situation.

When it comes to finding solutions for periop-

erative needs, I want to open my AORN Journal

and read about the issues I face every day and

how other perioperative RNs have resolved them.

I am excited that the Journal wants to be the

leader in showcasing ASC perioperative nursing.

I know there are talented and hard-working ASC

leaders, managers, and nurses who just need a

little push to get them to share what they are

doing and how they are surviving in health

care today. What better place to share this

information than in the Journal?

References1. ASCs: a positive trend in health care. Ambulatory Sur-

gery Center Association. http://www.ascassociation.org/

AdvancingSurgicalCare/aboutascs/industryoverview/

apositivetrendinhealthcare. Accessed August 21, 2014.

2. Facts on US hospitals. American Hospital Association.

http://www.aha.org/research/rc/stat-studies/fast-facts

.shtml. Accessed August 13, 2014.

3. Ambulatory surgery centers may soon outnumber hospi-

tals [The Daily Briefing]. The Advisory Board Com-

pany. http://www.advisory.com/Daily-Briefing/2013/

01/31/Ambulatory-surgery-centers-may-soon-outnumber

-hospitals. Accessed August 21, 2014.

Sarah Logue, BSN, RN, CNOR, LHCRM, is

director of nursing at Paddock Park Surgery

Center, Ocala, FL. Ms Logue has no declared

affiliation that could be perceived as posing a

potential conflict of interest in the publication of

this article.

AORN Journal j 533