developing a fair for validating skill...

The Joint Commission (2010) standard for Ambulatory Care nursing practice statesthat all staff will be competent to perform their responsibilities Their rationale for compe-tency standards is ldquoThe safety and quality of care treatment or services are highlydependent on the people who work in the organizationrdquo (The Joint Commission 2013)An element of performance for this standard requires that ldquothose who work in the organ-ization are competent to complete their assigned responsibilitiesrdquo (The Joint Commission2013) The American Academy of Ambulatory Care Nursing (AAACN) (2010) alsoaddresses competency in their standards of professional performance as a standard andcriteria for practice Registered nurses maintain their competency through life-long learn-ing in diverse educational experiences and activities (AAACN 2010) As professional nurs-es we adhere to these standards and maintain or obtain the needed knowledge and skillsfor ambulatory care nursing practice

The American Nursesrsquo Association (ANA) (2010) defines competency as ldquoan expectedand measureable level of nursing performance that integrates knowledge skills abilitiesand judgment based on established scientific knowledge and expectations for nursingpracticerdquo (p 64) Additionally competence is further defined as the quality of having suf-ficient knowledge aptitude judgment skill and ability to perform the duties and respon-sibilities of the position (US Department of Veterans Affairs Veterans HealthAdministration amp VA Great Lakes Health Care System 2012) This policy requires thatldquocompetence of all employees is assessed maintained demonstrated and improvedupon initial employmenthellipand on an ongoing basisrdquo (US Department of Veterans Affairset al 2012 p 1)

Program DevelopmentMembers of the Primary Care Quality Improvement (QI) Council a part of nursing

shared governance structure at Clement J Zablocki VA Medical Center identified that asystem for skill competency assessment specific to Primary Care nursing staff roles or

The Official Publication of the American Academy of Ambulatory Care Nursing

Page 3Telehealth Trials amp TriumphsYour Caller May Be a Victim

Page 4Self-Injection ClassesEmpowering Patients And Decreasing Nursing Workload Free education activity for AAACN members

2Health Care ReformOpportunities for the Uninsured to Access Affordable HealthInsurance and Care

Page 13Health Bytes

Page 14Member Spotlight

Page 15Safety Corner

Volume 35 Number 6

NOVEMBERDECEMBER 2013

continued on page 8

AAACN extends holidaywishes to all ofour members Atthis time of yearwe reflect on ouraccomplishments over thepast year and know ourachievements would nothave been possible withoutyour support of the associa-tion through your member-ship We wish you and yourfamily the very best of healthand happiness in 2014

Rebecca S BennettStacy A OlsonCourtney E Wilson

Mary Lee BarrettAngela Pereira

Michael S JanczyLou Yang

Developing a Fair For Validating Skill

Competence

Developing a Fair For Validating Skill

Competence

IAAACNrsquos Core Business ndash

LeadershipGreetings from your Board of Directors

In this Presidentrsquos Message I have the pleasure of giv-ing you an update from the SummerFall Board of DirectorsMeeting held in August at the National Office in PitmanNew Jersey It was a wonderful opportunity to work togeth-er with colleagues in person rather than our usual monthlytelephone conference calls We did a lot of work and bal-anced that with a lot of fun as well

AAACN is involved in a multitude of initiatives and proj-ects in addition to our everyday activities The RN CareCoordination and Transition Management (RN-CCTM) CoreCurriculum is in process Author teams are busy completingthe chapters that represent each of the nine core dimen-sions of care coordination identified by the previous expert panels Publication ofthe Core is expected in mid-2014 We will soon being developing the RN-CCTMcourse consisting of online education modules

We are considering a collaborative effort with a credentialing organization tooffer an exam that would provide a ldquocertificaterdquo to the person completing thecourse A certificate is an attestation that one has completed the coursework andpassed an exam This is not a certification which would include additional creden-tials after onersquos name but could possibly be the first step toward a certification inthe future Further discussion is needed prior to final decisions being madeContinued updates will be available in future Messages

The Ambulatory Care Certification Review Course (CRC) is taking on a new lookndash it will be offered as part of the Intensive CE Series from Gannett Education as anonline course consisting of four reading modules and five Webinars beginningearly next year The course is based upon the very successful CRC that has beenoffered over the past 13 years by AAACN We expect to continue to offer the ldquoliverdquoCRC at the AAACN Annual Conference and on demand Those interested inbecoming certified will now have four ways to prepare for the exam by taking ardquoliverdquo in-person course by purchasing the CRC DVD individually or as part of asite license in the Online Library or by participating in the online GannettAmbulatory Care Nursing Certification Intensive CE Series I am hopeful that withthese alternatives we will see an increase in the number of ambulatory certifiednurses in the near future

In preparation for the Board meeting members were asked to read Road toRelevance the sequel to Race for Relevance which we read last year Both bookspublished by the American Society of Association Executives offer organizationsthe opportunity to evaluate their relevance and value to their members and todetermine what will continue to keep them relevant in the future As a result webegan a discussion about the ldquocore businessrdquo of AAACN by asking ldquoWhat is ourmain focus or essential activity that sets us apart from other nursing and profes-sional organizationsrdquo The answer LEADERSHIP and Leadership Development

AAACN has developed nurses and leaders throughout its history ndash throughannual conferences networking and discussion groups development of stan-dards a core curriculum and a certification review course for ambulatory care andtelehealth Special Interest Groups (SIGs) continuing education scholarships andawards and numerous volunteer opportunities for personal and professionaladvancement However development of leaders does not happen on its own

As an organization we draw upon our core strengths and the areas in whichwe excel to promote leadership among all ambulatory care nurses The Board isreviewing the products services and programs AAACN provides in light of our

2 ViewPoint NOVEMBERDECEMBER 2013

Reader ServicesAAACN ViewPointAmerican Academy of Ambulatory CareNursingEast Holly Avenue Box 56Pitman NJ 08071-0056(800) AMB-NURSFax (856) 589-7463Email aaacnajjcomWeb site wwwaaacnorg

AAACN ViewPoint is a peer-reviewed bi-monthly newsletter that is owned and pub-lished by the American Academy ofAmbulatory Care Nursing (AAACN) Thenewsletter is distributed to members as adirect benefit of membership Postage paid atDeptford 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 AAACNs newslet-ter Web site and other promotional and edu-cational materials

For manuscript submission informationcopy deadlines and tips for authors pleasedownload the Author Guidelines andSuggestions for Potential Authors availableat wwwaaacnorgViewPoint Please sendcomments questions and article sugges-tions to Managing Editor Katie Brownlow atkatieajjcom

AAACN Publications andProductsTo order visit our Web site wwwaaacnorg

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

SubscriptionsWe offer institutional subscriptions only Thecost per year is $80 US $100 outside USTo subscribe call (800) AMB-NURS or (856)256-2350

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

copy Copyright 2013 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 andor advertisers and donot necessarily reflect the views of AAACNAAACN ViewPoint or its editorial staff

Publication Management is provided by Anthony J Jannetti Inc which is accreditedby the Association Management Company

Institute

Susan M Paschke

continued on page 11

WWWAAACNORG 3

Your Caller May Be a Victim

Intimate Partner Violence Hidden Facts Domestic violence more recent-

ly called intimate partner violence isalive and well in the United States Infact the Centers for Disease Controland Prevention (CDC) (2013) regarddomestic violence as a ldquoserious pre-ventable public health problemrdquoAccording to the National CoalitionAgainst Domestic Violence (NCADV)(2007) one in four women experi-

ence intimate partner violence while one in seven men is avictim Domestic violence crosses all socioeconomic bound-aries ages sexual orientation and races

Domestic violence can take many forms We are perhapsmost familiar with physical violence where bruises andinjuries are apparent Emotional and sexual abuse is just asreal however due to the lack of outward physical signs theyare much more difficult to detect Psychologicalemotionalviolence involves trauma to the victim caused by acts threatsof acts or coercive tactics (CDC 2013) Psychologicalemotional abuse can include but is not limited to humili-ating the victim controlling what the victim can and can-not do withholding information from the victim deliber-ately doing something to make the victim feel diminishedor embarrassed isolating the victim from friends and fami-ly and denying the victim access to money or other basicresources If your caller reveals any of these experiences itis a red flag that he or she may be experiencing domesticviolence

Due to the private nature of this abuse and a sense ofshame the victim may conceal this crime At times victimsare not even aware that what they are being subjected to isdomestic violence As nurses it behooves us to understandwhat abuse is and how it can be manifested in a patientbecause most often patients are not forthcoming aboutthe abuse they are experiencing

Your Caller May Share Her Secret with YouAs a telephone triage nurse you will undoubtedly have

contact with victims of domestic violence One study indi-cated that 25 of females patients seeking care at a pri-mary care clinic were victims of some type of domestic vio-lence within the past year (Minsky-Kelly Hamberger Papeamp Wolff 2005) How can you effectively assess for domesticviolence Conveying a sense of support respect dignityand empathy is important for all patients Victims of domes-tic violence are especially sensitive to the nursersquos attitudeThese patients feel fearful helpless desperation and self-loathing They blame themselves and may feel that theydeserve the treatment they receive The nursersquos communi-

cation style may determine if the patient feels safe to shareher predicament

A woman may call complaining of extreme anxiety anddifficulty sleeping Ask the typical questions about sleephabits and also ask about life circumstances Rather thandirectly ask if the caller is experiencing abuse it can be morehelpful to inquire about relationships Remember she maynot yet understand that what she is experiencing is abuseldquoDo you have a supportive partner Who helps you copewith your anxiety What makes you feel more anxiousrdquoThese questions may prompt answers that reveal she is walk-ing on eggshells and is being controlled by her partner

If a caller is inquiring regarding a physical injury aboutwhich you have suspicions (for example her explanation ofhow the injury occurred does not make sense and you sus-pect abuse) do a brief safety assessment Does she feel safeat home Has she experienced many injuries at home Youcan remind her that it is never right for her to be injured byanother person and advise her to seek medical care andfacilitate the process of her entry into the system

Listen for comments the caller makes that indicate sheis not free to make her own decisions regarding her bodyher social activities or finances The caller may be askingyou a question when suddenly her voice becomes muchmore cautious and you become aware that the perpetratorhas entered the room This is a signal that the caller doesnot have the liberty to speak freely to you

Often the call is not made in regard to the domesticviolence but is instead in regard to a ldquoside effectrdquo of theexperience Listen carefully for the question behind thequestion

Be Prepared and Have a PlanIt is helpful to formulate a statement that provides

information to a caller you suspect may be a victim ofdomestic violence In this way you can offer validation andresources in a non-threatening fashion For example youcan share the definition of domestic violence and contactinformation for local domestic violence shelters You couldsay ldquoItrsquos important to be aware of the support andresources here in our community for domestic violence vic-tims Here is the phone number for our local agency in caseyou need itrdquo If your community does not have a localagency be sure you have at hand the phone number of atleast one national agency that offers toll-free telephone sup-port for victims of domestic violence

You May Have Your Own SecretIf you have been a victim of domestic violence yourself

you may suffer panic or flashbacks when you suspect acaller is experiencing abuse It may be tempting to tell thepatient what to do and that she needs to leave the situationimmediately However professional boundaries must beobserved You may share an idea by stating ldquoWomen in a


Do you have a story that has been memorableor has had an impact on your practice If you would like anopportunity to share it in the ldquoTelehealth Trials amp Triumphsrdquocolumn contact Kathryn Koehne at krkoehnegundluthorg

Kathleen Swanson


Historically nursing workload hasbeen the subject of professional inter-est and scrutiny For the ambulatorycare setting at The Villages VeteransAdministration Outpatient Clinic inCentral Florida monitoring workloadis a necessity This clinic serves aunique population of patients in closeproximity to The Villages one of thelargest retirement communities in thenation The Villages is located onehour north of Orlando Florida andaccording to the United States CensusBureau (2013) the population therewas 51442 in 2010 with 698 ofthe population over 65 years of agePresently the clinic serves over 13000patients with an enrollment waiting listof over 400 Since the clinic opened in2010 several performance improve-ment projects have been initiated tohelp improve patientsrsquo access to careas well as decrease nursing workload

According to a study byDickenson Cramer and Peckham(2010) data and metrics used to eval-uate and document effectiveness ofnursing workload may not accuratelyreflect staffing needs which ultimatelyaffects the delivery of safe patient careThese researchers noted that therewere ldquomany similarities in nurse workperformed in disparate clinics yetwork processes and workflows variedbased on the needs of differing patientpopulationsrdquo (p 39)

In general the ambulatory caresetting utilizes registered nurses toserve a high volume of patients deal-ing with a variety of individual patientissues within a 24-hour period (Mastal2010 p 267) Some challenges iden-tified in ambulatory care settingsinclude improving workflow efficiencyoptimizing human and materialresources in a cost-effective mannerand providing nursing services using avariety of high-tech methods in virtual

environments in addition to traditionalface-to-face care (Swan 2008 p 195)Since each primary care nurse at theclinic is responsible for up to 1200patients the issue of workloadbecomes quite important

At the clinic the current patientflow process is the following Physicianssee patients every 30 minutes The pri-mary care nurse working with eachphysician assesses each patient prior tothe physician visit This process takesapproximately 15 minutes andincludes vital signs evaluation andadministration of immunizations pro-cedures (such as EKGs) and requiredhealth screenings Areas of additionalassessment include falls post-traumaticstress disorder (PTSD) and depressionamong others One patient may haveup to 15 of these additional assess-ments to evaluate Patients are asked toarrive for their physician appointments30 minutes early allowing the RN tocomplete the assessment processbefore the pa tientrsquos meeting with thedoctor Unfortunately patients oftenarrive exactly at the scheduled appoint-ment time or they arrive late leavinglittle or no time for the RN to completethe necessary nursing assessments andprocedures

In addition to conducting prelimi-nary patient assessments for the physi-cian RNs conduct separately scheduled30-minute ldquonurse visitsrdquo In jectionshealth education equipment trainingand any other required follow upoccur during these appointments AnRN typically has one nurse visit in themorning and one in the afternoonHowever RNs routinely have to ldquoover-bookrdquo these nurse visits completingseveral each day to accommodatepatient needs The above factors allcontribute to an unacceptable work-load for the RN and a lack of access tocare for the patients

Instructions forContinuing Nursing

Education Contact HoursSelf-Injection Classes EmpoweringPatients and Decreasing Nursing

WorkloadDeadline for Submission December 31 2015

To Obtain CNE Contact Hours1 For those wishing to obtain CNE contact

hours you must read the article and com-plete the evaluation online in the AAACNOnline Library ViewPoint contact hoursare free to AAACN members

bull Visit wwwaaacnorglibrary and log inusing your email address and password(Use the same log in and password foryour AAACN Web site account and OnlineLibrary account)

bull Click ViewPoint Articles in the navigationbar

bull Read the ViewPoint article of your choos-ing complete the online evaluation forthat article and print your CNE certificateCertificates are always available underCNE Transcript (left side of page)

2 Upon completion of the evaluation a cer-tificate for 13 contact hour(s) may beprinted

FeesMember FREE Regular $20

ObjectivesThe purpose of this continuing nursing

education article is to describe an education-al initiative aimed at reducing nursing work-load and improving timely access to care forpatients in an ambulatory care setting Afterreading and studying the information in thisarticle the participant will be able to1 Discuss the importance of decreasing

nursing workload in the ambulatory caresetting

2 List two benefits of the self-injection pro-gram as implemented by The Villages VAOutpatient Clinic

3 Identify one area where patient educationmight be utilized to decrease nursingworkload in the readerrsquos workplace ororganization The author(s) editor and education director

reported no actual or potential conflict of interest inrelation to this continuing nursing education article

This educational activity has been co-provided byAAACN and Anthony J Jannetti Inc

AAACN is provider approved by the California Boardof Registered Nursing provider number CEP 5366Licensees in the state of California must retain this cer-tificate for four years after the CNE activity is completed

Anthony J Jannetti Inc is accredited as a providerof continuing nursing education by the AmericanNurses Credentialing Centers Commission onAccreditation

Self-Injection Classes EmpoweringPatients and Decreasing Nursing Workload

Anne SolowJulie AlbanMarion Conti-OrsquoHare

Continuing NursingEducationEducationEducation

FREE

WWWAAACNORG 5

AssessmentPlan-Do-Check-Act (PDCA) is a

performance improvement (PI) modelused for designing new and modifyingcurrent processes In the Plan phase ofthe cycle a need to improve a processis identified Data are then analyzedand theories are tested and imple-mented in the Do part of the cycleResults and effectiveness are measuredin the Check section and lastly in Actplans are made to hold onto the gainsmade or an act to improve and stan-dardize improvements is implement-ed In the VA system this method isused to support and enhance theimplementation of PI with the ulti-mate goal to continually improve cur-rent systems and achieve excellence inmeeting the needs of patients throughimproved outcomes

In 2011 a PDCA model ldquoIm -proving Access to Care for Patientswith Non-VA Prescriptionsrdquo (Pelkey etal 2011) was created at the facilitybecause patients requesting their non-VA prescriptions be filled at the clinicmust be evaluated by a primary carenurse This analysis of the PDCArevealed that 40 of all nurse visits atthe clinic from January 1 2011 toFebruary 28 2011 were made forinjections In addition results indicat-ed that 80 of all injections given inthis same time period were either fortestosterone or vitamin B12 injections(see Figure 1)

A contributing factor to the needfor addressing the injection volume

included the high rate of physiciansordering these two injectable medica-tions for The Villages patient popula-tion Current research has shown thebenefits of vitamin B12 and testos-terone replacement therapy especiallyin the aging population For examplevitamin B12 has been shown todecrease the incidence of depressionin older adults (Skarupski et al 2010)Other studies have associated vitaminB12 therapy with an increase of cogni-tive function in older adults (DonovanHorigan amp McNulty 2011) Furthertestosterone replacement has beenwidely used for treatment of erectiledysfunction (ED) low energy and sev-eral other symptoms related to lowserum testosterone in older adultpatients (Khera Morgentaler ampMcCullough 2011)

Armed with this information nurs-ing administration chose to furtherevaluate opportunities for workflowimprovement due to the inability ofthe RNs to accommodate the largevolume of patient visits This led to aninitiative for reducing nursing work-load by teaching patients self-injectionof these medications

PlanThe assistant chief nurse and the

nurse manager of primary care deter-mined that teaching self-injection topatients of these selected two medica-tions would reduce the total numberof injections given monthly at nurseclinic visits thereby reducing thedemand for this particular nurse visit

appointment freeing up RN time forother patient care responsibilities andimproving access to care Other bene-fits of teaching patients self-injectionincluded fostering patientsrsquo feelings ofindependence empowerment andthe ability to travel more easily (HileyHomer amp Clifford 2008)

Other injectable medicationssuch as insulin were not included inthis initiative because they requiredindividual patient health teachingrelated to a specific diagnosis A class-room format was chosen because onlyone nurse would be required to teacha large number of patients

ImplementationThe self-injection class included a

PowerPointTM presentation demon-stration actual practice with returndemonstration and a take-homebooklet giving comprehensive injec-tion instructions to those patientsinterested in and able to perform self-injection The PowerPoint presentationand booklet were approved by theChair of Patient Education in NorthFloridaSouth Georgia Veterans HealthSystem (NFSGVHS) of which the clin-ic is a part This approval process in -cluded ensuring that the class contentand patient handouts were written ata fifth grade level or lower a currentstandard for patient education at theVeterans Administration All injectionprocedure content was derived fromthe current Lippincott Nursing Proce -dure Manual

Primary care nurses and providersscreened and referred patients for self-injection based on the need for fre-quent injections of testosterone andvitamin B12 Classes were then sched-uled for the second Thursday of everymonth from 200 pm to 300 pmPatients and spouses or significant oth-ers were given 30 minutes of didacticeducation including proper subcuta-neous and intramuscular injectiontechnique and medication safety Ap -proximately one out of three patientswho felt uncomfortable about self-injection requested that their signifi-cant other or caregiver be trained toadminister home injections

Thirty minutes of practical instruc-tion and return demonstration usinginjection equipment and oranges forpractice followed the didactic sessionSince administering injections is a psy-

Figure 1Injection Type Pie Chart

January to February 2011

PPD(n=2)

Hep B(n=1)

DTap(n=4)Zoster

(n=6)Epogen (n=1)

Zoladex (n=2)

B-12(n=28)

Testosterone(n=38)


chomotor skill patients were evaluat-ed during class by observing their per-formance of motor skills and assessingthe cognitive skills essential for theadaptation of the procedure for safepractice (McDonald 2007) If patientswere unable or unwilling to safely per-form the injection techniques due tophysical psychological or cognitivefactors they would remain on thenurse injection schedule at the clinicThese options were presented topatients at the beginning of each classto help reduce anxiety

Documentation of class atten-dance was entered into the individualmedical records noting patients hadcompleted the class and were thendeemed competent to perform self-injection After satisfactory completionof the self-injection class the patientrsquosprimary care providers and nurseswere alerted to this fact Providerswould then write orders for medica-tion and supplies and the nurse wouldbe able to follow up with patients andobserve their first self-injection ifneeded Patients were removed fromthe clinic injection schedule andbegan to receive their medicationsand injection supplies at homethrough the US mail They weregiven the option to keep their nextnurse visit if they felt the need to besupervised during their first self-injec-tion In addition patients were en -couraged to call the clinic and theirprimary nurse if they had any ques-tions or problems

EvaluationEvaluation forms were created

Using a Likert scale patients wereasked to rate the presenter and theclass content as well as evaluate them-selves on their level of understandingof the subject matter and their injec-tion skills following the classSpecifically patients were asked toevaluate the content speakerrsquos level ofknowledge and presentation styletiming and organization of the classand the quality of the handout Inaddition patients were asked to evalu-ate the topics discussed in the classwhich included medication safety dif-ferences between subcutaneous andIM injection proper injection tech-nique and how to dispose of needlesSubjective data was also collected forongoing analysis of the effectiveness ofthe self-injection program Patient

feedback from classes to date has beenoverwhelmingly positive and patientsand their significant other or caregiverhave expressed gratitude for theinstruction For example patientsoften wrote they appreciated learninghow to ldquodo it rightrdquo and they nowldquofeel confident to injectrdquo themselves

Comments includedldquoHands-on training was greatrdquoldquoThe most helpful part of the class

was getting to know the differencebetween Sub-Q and IMrdquo

ldquoI learned how to do it (injection)correctlyrdquo

ldquoIt was most beneficial to learnabout correct injection sitesrdquo

ldquoLearning about the proper tech-nique for injection was most helpfulrdquo

ldquoI learned about proper needlesafetyrdquo

ldquoIt was helpful to see it liverdquoldquoBeing able to do it myselfrdquo

A benefit of the program wasincreased convenience for the patientby reducing the frequency of clinic vis-its This outcome was not reportedspecifically in class evaluations howev-er informal feedback to primary carenurses over the months following classattendance validated this findingSince the inception of the programonly 6 of patients have opted toreturn to scheduling clinic visits forinjections

Injection data were again collect-ed from January 1 2012 to February

28 2012 and compared to matchingdata from the same time frame in2011 Results showed that sincebeginning the self-injection programthe total number of nurse visits haddecreased by 30 and the total num-ber of testosterone and B12 injectionappointments decreased by 74These results suggest that the self-injection class has positively impactednursing workload over the last year(see Figure 2) With a decreased injec-tion workload RNs at the clinic havehad more time to track high-riskpatients with chronic problems suchas uncontrolled hypertension and highhemoglobin A1c levels for diabetesNurses are then able to intervenethrough education and individualizedfollow up allowing them to use theirexpertise in disease management andprevention

Expanding Our InfluenceSince the inception of the self-

injection class the content includingthe PowerPointbooklet has beenplaced on the NFSGVHS Web siteunder Patient Education and has beenaccepted as the standard content forself-injection education throughoutNFSGVHS Handouts from this sitecan be downloaded and distributed topatients

Another opportunity the VA usedto further implement this program isthe use of telehealth technologywhere audiovisual equipment is usedto facilitate simultaneous patient edu-

Figure 2Injection Chart

Pneu

mon

ia0

5

10

15

20

25

30

35

40

20112012

Testo

stero

neB-

12

Zolade

x

Epog

en

Zoste

rDTa

pHep

BPP

D

WWWAAACNORG 7

cation in multiple locations Accordingto Coyle Duffy and Martin (2007)use of telehealth technology increasespatient access to care and can be usedto provide education treatment followup data collection and promotesincreased communication betweenpatients and their health care team Inconjunction with recent national VAmandates The Villages clinic hasestablished several telehealth providerclinics and patient education opportu-nities Self-injection classes have beenincluded in this initiative and the clin-ic has been broadcasting these classesmonthly to other local clinics withinthe system Clinics receiving the classtransmission have assigned an LPNtelehealth technician to assist inobserving the patientrsquos injection tech-niques in real time during class TheLPN telehealth technician also activelycommunicates with primary careteams in their respective clinics andhelps the primary care nurses identifypatients for self-injection class Patientparticipation is documented at eachsite and class evaluations are complet-ed and returned to the RN instructor atThe Villagesrsquo clinic

ConclusionPatient injections specifically

testosterone and vitamin B12 consti-tuted 80 of the total injections givenat The Villages VA Outpatient Clinicduring the period between January toFebruary 2011 (Pelkey et al 2011) Byproviding self-injection classes topatients receiving these medicationsthe demand for the associated nursevisit appointment decreased by 74Training patients to give themselvesthese injections has also allowed themto be more independent in this area oftheir health care In addition usingtelehealth technology and standardiz-ing the self-injection programthroughout the NFSGVHS more vet-erans and nurses will be able to takeadvantage of this education

The goals and values of this VA-ini-tiated program can be beneficial toother health care organizations Byincreasing access to care improvingworkflow efficiency and decreasingtheir workload nurses are freed to takeon more complex responsibilitieswhile maximizing patient care out-comes

ReferencesCoyle MK Duffy JR amp Martin EM

(2007) Teachinglearning health-pro-moting behavior through telehealthNursing Education Perspectives 28(1)18-23

Dickson KL Cramer AM amp PeckhamCM (2010) Nursing workload meas-urement in ambulatory care NursingEconomics 28(1) 37-43

Donovan CO Horigan G amp McNultyH (2011) B-vitamin status and cogni-tive function in older people Journal ofHuman Nutrition and Dietetics 24281-282

Hiley J Homer D amp Clifford C (2008)Patient self-injection of methotrexatefor inflammatory arthritis A studyevaluating the introduction of a newtype of syringe and exploring patientsrsquosense of empowerment Musculo -skeletal Care 6(1) 15-30

Khera M Morgentaler A ampMcCullough A (2011) Long-actingtestosterone therapy in clinical prac-tice Urology Times 2-7

Mastal MF (2010) Ambulatory care nurs-ing Growth as a professional special-ty Nursing Economic$ 28(4) 267-275

McDonald ME (2007) The nurse educa-torrsquos guide to assessing learning out-comes (2nd ed) Sudbury MA Jones ampBartlett Publishers

Pelkey ME Alban J Farrell E Rivera-Melendez L Coffey S Loza B hellip

Dhanpat R (2011 May) Improvingaccess to care for patients with non-VAprescriptions Poster session presentedat the 37th Annual Conference of theAmerican Academy of AmbulatoryCare Nursing Lake Buena Vista FL

Skarupski KA Tangney C Li HOuyang B Evans DA amp MorrisMC (2010) Longitudinal associationof vitamin B-6 folate and vitamin B-12 with depressive symptoms alongolder adultsover time AmericanJournal of Clinical Nutrition 92 330-335

Swan BA (2008) Making nursing-sensi-tive quality indicators real in ambula-tory care Nursing Economic$ 26(3)195-201205

United States Census Bureau (2013) Stateand county QuickFacts [data file]Retrieved from httpquickfactscensusgovqfdstates121271625html

Anne Solow MSN RN-BC is a PrimaryCare PACT RN The Villages VAOutpatient Clinic The Villages FL

Julie Alban MSN MPH RN-BC is aPACT Care Coordinator The Villages VAOutpatient Clinic The Villages FL

Marion Conti-OrsquoHare PhD RN is anOnline Nursing Instructor FruitlandPark FL

M Elizabeth Greenberg Appointed to AAACN Board of Directors

M Elizabeth ldquoLizrdquo Greenberg RN-BC C-TNPPhD has been appointed to the Board of Directorseffective at the close of the AAACN 2014 AnnualConference Liz will complete the remaining two-year term of Nancy May MSN RN-BC who willvacate her Director position to serve as President-Elect of AAACN Liz was a candidate on the 2013ballot

Liz is Assistant Clinical Professor at NorthernArizona University School of Nursing and a nation-

ally recognized leader in the field of telehealth nursing Liz has been a vol-unteer leader in AAACN for several years She is currently serving as amember of the ViewPoint Editorial Board Lizrsquos 30 years of nursing experi-ence in telephone nursing practice management and research will be adefinite asset to the board

M Elizabeth Greenberg


Council members identified 15 skills specific to thePrimary Care clinics (see Table 1) Prioritization of skills wasdetermined through discussions with managers and physi-cians peer interviewing and direct observation of skillsperformed Examples included improperly placed ECGleads incorrect oxygen flow rate used in hand held nebu-lizer administration incomplete documentation of tele-phone assessments and intramuscular injections into sitesnot approved by policy

Due to the small size and composition of the councilthey were limited in their ability to implement the educa-tion and validation for all 15 identified skills at one fair Thecouncil also felt it may be too overwhelming to present allof the skills at once Therefore it was determined the skillsfair would be split into two ldquophasesrdquo Phase one wouldconsist of the most frequently performed skills or thosedetermined to be of higher risk and with observed variabil-ity These included skills 1-8 in Table 1 The remaining skills9-15 (see Table 1) were planned for implementation inPhase Two Individuals in each clinical role would berequired to complete the skill competencies within thescope of their practice

The Primary Care QI Councilrsquos goal was to have the fairdeveloped within six months from the initiation of theidea The project began in April with the intent of havingthe education completed in October The Primary CareDepartment does not have a nurse educator or other edu-cation support personnel therefore council members cre-ated the educational presentations and skill competencyvalidation methods for the program The hospitalrsquos evi-dence-based policies the approved online procedurebook and evidence from the literature review were used to

patient population had not been established The councilrecognized that the lack of such validation and documen-tation of staffrsquos knowledge and ability to perform patientcare was a deviation from the AAACN and The JointCommission standards for competency as well as fromorganizational policy and best practice

Through discussion among council members clinicmanagement and clinical staff two areas of concern arose1) not all staff performed skills in the same manner and 2)some staff were not aware of hospital policy and proce-dures specific to Primary Care Conversations with staffmembers and direct observations of patient care revealeda variance in skill performance as well as a knowledgedeficit of organizational policy and procedure in severalareas Based on the knowledge that quality of care is direct-ly related to the competency of staff (The JointCommission 2010) the QI Council decided to focus onskill competence in Primary Care as a priority for qualityassurance

The QI Council began with a literature search relatedto the development of a competency validation programFour articles were retrieved and evaluated with the assis-tance of a doctoral-prepared nurse researcher employed bythe organization to facilitate evidence-based practice andresearch projects Jankouskas and colleagues (2008)described a successful process for development of skillcompetencies The council used this article in preparationof the fair Additionally the council determined that thestyle of a fair for education and skill validation would bemost conducive to the needs of the Primary CareDepartment The relaxed atmosphere of a ldquofairrdquo settingdecreases anxiety adult learners may experience duringtesting and skill demonstration (Ford 1992) Finally withconcerns among health care professionals of the need todemonstrate nursing skill competency in relation to theprovision of quality of care and consumer protection(Minarik 2005) the council believed this was a meaning-ful project The program would establish a baseline com-petency validation of skills performed in Primary Care byclinical staff It could then be refined to address the evolv-ing learning needs of the department

PlanSince sufficient evidence was found in the literature to

support the development and implementation of a skillsfair to validate staff competency in performing specific pro-cedures the council decided to progress with the projectThe Plan Do Study Act (PDSA) model was used to devel-op the skills fair with the goal of validating competence ofskill performance in 100 of clinical staff in Primary CareThe initial step in the PDSA was the formation of a team tocreate and implement the skill competency validation pro-gram The teamrsquos core was the Primary Care QI CouncilBased on the competencies selected for validation otherspecialties were invited to participate in selected skill sta-tions including Employee Health and Laboratory Science

1 Calling the rapid response team (parameters andprocess for calling for a critically ill patient)

2 Ear irrigation3 ECG performance (focused on lead placement and

rationale)4 Glucometer testing5 Handheld nebulizer administration6 Intramuscular and subcutaneous injections7 RN assessment tool (algorithm for thorough

complete documentation of assessments)8 Tuberculin skin test administration and

interpretation9 Bladder ultrasound10 Blood pressure measurement11 Clean catch urine specimen collection12 Indwelling catheter insertion care and urine

specimen collection13 Phlebotomy14 Postural vital signs measurement15 Visual acuity

Table 1 Skills Identified for Primary Care Clinical Staff

Competency Validation

Skill Competencecontinued from page 1

WWWAAACNORG 9

develop learning objectives educational and skill contentand return demonstration or test

The council attempted to accommodate multiplestyles of learning to best convey the educational contentand skill demonstration (Jankouskas et al 2008 Sprenger2008) Each skill was presented at an individual station andincluded a poster presentation (visual learning style) livepresenters at each station (audio learning style) and ifapplicable simulation or actual return demonstration ofthe skill being taught (hands-on learning style) The coun-cil created dynamic and engaging educational posters byreferencing an evidence-based presentation on posterdevelopment that was held at their facility

The council developed the method by which each skillwould be evaluated This was based on the informationbeing taught and how best to have the learner demon-strate competency or retain this knowledge Validationmethods included a passing score of 85 or higher on awritten test and return demonstration of the skill (if appli-cable to content) Printed handouts were given to thelearner for future reference to reinforce education All clin-ical staff were required to attend and successfully completeall skills

Implementation (Do)To meet the mandatory attendance requirement mul-

tiple fairs were held to accommodate any potential sched-ule conflicts staff members may have Five separate skillsfairs were hosted one for each of the five clinics to coincidewith their protected time (non-patient care time allottedonce monthly for educational purposes) The fairs were heldover six weeks Four fairs were held in an educationconfer-ence room in the hospital The fifth fair was conducted atthe off-site clinic A two-hour time period was allotted tocomplete the fair allowing the participants an average of 15minutes at each skill station Staff were able to complete theeducation and competencies at their own pace

Upon arriving at the fair participants received a skillvalidation checklist and a post-fair evaluation form The val-idation checklist became part of the employeersquos personnelrecord This form listed each of the skills the method ofvalidation and the printed name initials and signature ofthe presenter To obtain a validation signature from eachskill stationrsquos instructor staff had to successfully completethe educational content test or return demonstrationAdditionally staff were instructed to anonymously com-plete an evaluation form after all requirements were metand leave it in the classroom for review by the council

Outcomes (Study)All 56 clinical staff (100) participated and all partic-

ipants achieved 100 skill competency validation meet-ing the PDSA goal Data were summarized from the post-fair evaluation forms of the 48 participants who completedat least part of the form All evaluations were positive andreflected the efforts put into the different educationalmethods (see Table 2)

Recommendations (Act)The skills fair for Primary Care clinical staff was success-

ful in meeting the aim of 100 skill competency Havingprotected education time in the clinics was critical to itssuccess The positive feedback from participants providesadditional evidence this is an effective means for validationof skills Some questions were asked to gather feedbackabout staff membersrsquo self-assessment of their learningneeds One question addressed their desired frequency fora skills fair (see Figure 1) The majority of participant feed-back supported an annual fair for education and skill com-petency This result was also supported by administrationand will allow the council to address all skills on a more fre-quent basis Future fairs will address validation of skills(numbers 9 to 15 in Table 1) as well as those identified byparticipants in their evaluation recommendations such aswound care dressing changes and intravenous catheterinsertion and care Based on this experience and partici-pant recommendations future skills fairs will be in a largercooler room and have more presenters assisting at certainstations Stations identified as needing additional presen-ters were those requiring return demonstration of skills inaddition to content such as tuberculin skin test and ECGlead placement

The skills fair took nine months to complete from ini-tial idea to the final fair exceeding the original goal of sixmonths One barrier to achieving a six-month goal was the

Question Response ()

1 Information was applicable 100

2 Learned something new to utilize in my practice

98

3 Materials were easy to understand 100

4 Adequate time was allowed 98

Table 2 Evaluations from Participants in the Skills Fair

(N = 48 Respondents)

Figure 1 Participant Preferences for Frequency of a Skills Fair

Other

Every 2 years

Annually

10

78

12


lack of available time away from direct patient care for thestaff on the council Council members were not alwaysable to attend every meeting due to scheduled patient careduring these time periods It was also difficult for themajority of staff to allot time specifically for the develop-ment of the education presentations Despite having pro-tected time many of those periods contain pre-scheduledtraining programs and presentations which council mem-bers are required to attend The organization has sinceapproved designated time away from assigned duties forall shared governance council members and leaders to sup-port their activities at the unit level Council chairpersonsand members now receive on a monthly basis eight andfour hours respectively of non-direct care time for sharedgovernance activities

The assistance of a doctoral-prepared nurse was bene-ficial in evaluating the literature However if an organiza-tion does not have this type of resource other masters-pre-pared nurses (such as clinical nurse specialists clinical nurseleaders nurse educators or faculty) may be available tostaff as consultants in appraising the literature and apply-ing evidence to implement a program Additionally forfuture skills fairs or other educational events it may be ben-eficial to have a graduate-level nurse educator reviewmaterials or assist with program evaluation Of note theorganization has instituted a formal staff competency vali-dation that verifies performance during patient care Askills fair is a stepping-stone to actual performance valida-tion as it can be an effective tool for providing the neces-sary education and practice to be able to apply knowledgeand skill to a real environment

The QI Council will invite the Primary Care EducationCouncil to partner in presenting future fairs because thegoal of the skills fair is within the scope of the NursingShared Governance Education Council The EducationCouncil will be able to align the fair with staff developmentgoals and the QI Council will then focus on initiating addi-tional quality improvement projects

ConclusionThe use of a skills fair as an educational method was

well received by colleagues Collaboration with staff inother specialties having the required expertise proved tobe an effective utilization of resources for example theemployee health nurse assisted with the tuberculin skin teststation The initial fair was a positive learning experiencefor the council as planners and teachers Future fairs willrequire significantly less preparation time because of coun-cil membersrsquo acquired knowledge and skill in this processThe educational plans and materials are already in place sominimal time would be required to review and update thematerial with any changes in policy or best practice Thisprocess has become a reality with the Phase Two skills fairbeing held at the time of this writing This second fair tooksix months from the councilrsquos decision to the last fair amarked decrease in time commitment The addition ofscheduled non-patient care time was essential for membersof the council to complete their competency educationmaterials in a much shorter period of time

The types of skills held at future fairs will be evaluatedon an annual basis by the council which will continue togather data from participants managers and clinic staffPotential problem prone areas that could be addressed infuture competencies may be identified from quality reportssuch as laboratory data patient satisfaction surveys or fromobservation of daily work to determine the current learningneeds of the department and identify opportunities forfuture fairs or other educational programs

In summary the QI Council for Primary Care was ableto develop an effective program for skill competency vali-dation In doing this the Primary Care Department is com-pliant with organizational policy for competency stan-dards as well as The Joint Commission and AAACNstandards for competency

ReferencesAmerican Academy of Ambulatory Care Nursing (AAACN) (2010)

Scope and standards of practice for professional ambulatory carenursing (8th ed) Pitman NJ Author

American Nurses Association (ANA) (2010) Nursing Scope andstandards of practice (2nd ed) Silver Spring MD Author

Ford L Wickham V amp Colver C (1992) Developing a skills fairworkshop enhancing competency performance Dimensions ofCritical Care Nursing 11(6) 340-346

Jankouskas T Dugan R Fisher T Freeman K Marconi S MillerH hellipZoller D (2008) Annual competencies through self-gov-ernance and evidence-based learning Journal for Nurses in StaffDevelopment 24(4) E9-E12

Joint Commission The (2013) Comprehensive accreditation manu-als [E-dition v5100 Ambulatory Care LD030601]Oakbrook Terrace IL Author

Minarik P (2005) Issue Competence assessment and competencyassurance of healthcare professionals Clinical Nurse Specialist19(4) 180-183

Sprenger M (2008) In Differentiation through learning styles andmemory (2nd ed pp 1-48) Thousand Oaks CA Corwin Press

US Department of Veterans Affairs Veterans Health Administrationamp VA Great Lakes Health Care System (2012) VISN policy mem-orandum 10N12-00-07 (rev 5) Assessment of employee compe-tence Chicago IL Author

Rebecca S Bennett BSN RN-BC is a Staff RN Clement J ZablockiVA Medical Center Milwaukee WI

Stacy A Olson BSN RN-BC is a Staff RN Clement J Zablocki VAMedical Center Milwaukee WI

Courtney E Wilson BSN RN-BC is a Staff RN Clement J ZablockiVA Medical Center Milwaukee WI

Mary Lee Barrett BSN RN is a Staff RN Clement J Zablocki VAMedical Center Milwaukee WI

Angela Pereira RN is a Staff RN Clement J Zablocki VA MedicalCenter Milwaukee WI

Michael S Janczy LPN is a Staff LPN at Clement J Zablocki VAMedical Center Milwaukee WI

Lou Yang LPN is a Staff LPN Clement J Zablocki VA MedicalCenter Milwaukee WI

Authorsrsquo Note No funding was received for this project The viewsexpressed in this article are those of the authors and do not neces-sarily reflect the position or policy of the Department of VeteransAffairs or the US government

Acknowledgement Appreciation is extended to Mary Hagle PhDRN WCC Nurse Scientist at Clement J Zablocki VA Medical Centerfor her encouragement and assistance

WWWAAACNORG 11

care business in an effort to substantiate their value andbenefit to our membership

The final day of the meeting was spent reviewing andupdating the AAACN Strategic Plan The plan has served uswell over the past three years in providing direction andguidance for our organization Board members were ener-gized by the ldquocore business discussionrdquo that served to vali-date our strategic plan as a good roadmap for the futureWe believe AAACN is well-positioned to continue to serveour members expand our influence and strengthen ourcore given the challenges ahead These are exciting timesfor our organization and for all of our members Manyopportunities exist for increasing your involvement ndash findone that is a good fit and go for it

Susan M Paschke MSN RN-BC NEA-BC is Chief QualityOfficer Visiting Nurse Association of Ohio Cleveland OH Shemay be contacted at spaschkevnaohioorg

Presidentrsquos Messagecontinued from page 2Plan Ahead for AAACN

May 19-22 2014Now is the time to plan ahead for the upcoming

2014 AAACN Annual Conference Herersquos a quick peakinto what is being planned for you for the conference

The pre-conference is scheduled for Monday May19 2014 entitled ldquoBest Practices in Caring CreatingPositive Presence and Peace in Nursingrdquo The pre-confer-ence will be led by co-presenters Barb Pacca BSN RNCPN HTP Childrenrsquos Hospital of Philadelphia along withMary Laffey Adams MSN RN St Louis ChildrenrsquosHospital The presentation will address the concepts ofmindfulness nursing presence and the nurse as aninstrument of healing along with evidence based effectsof mindfulness on the mind body and spirit

After the opening address by Susan Paschke MSNRN-BC NEA-BC President our keynote speaker DonnaWright MS RN will follow with an engaging discussionto keep our spirits high and our enthusiasm peaked forthe speakers to come Donna is a consultant withCreative Healthcare Management She has spoken tonational and international nursing audiences on the top-ics of relationship based care Nursing Magnetcopy certifica-tion leadership and competency assessment

Stay tuned for more updates of the upcoming con-ference in future issues of ViewPoint

Carol Ann AttwoodMember Program Planning Committee

LVM Systems Inc4262 E Florian Avenue Mesa AZ 85206

wwwlvmsystemscom

Corporate members and affiliates receive recognition in ViewPoint on AAACNs Web site and in various conference-related publications as well as priority booth placementat AAACNs Annual Conference For more information about Corporate Member or Affiliate benefits and fees please contact Marketing Director Tom Greene attomgreeneajjcom or 856-256-2367

eHealth Technologies140 Allens Creek Road Rochester NY 14618

wwwehealthtechnologiescom48 Franklin Street Framingham MA 01702

wwwnightnursetriagecom

Night Nurse has delivered reliable telephone triage services to thepediatric medical community since 1999 Patients receive the higheststandard of timely triage from experienced RNs and NPs averaging 18years of pediatric clinical experience Advanced systems and cost effi-cient operations support the competency of our nurse professionalsresulting in affordable quality triage services for growing numbers ofNight Nurse subscribers and their patients

Interested in Writing For

Consider sharing yourambulatory care or telehealthnursing expertise by writing anarticle for ViewPoint Downloadauthor guidelines copydeadlines and tips for authorsat wwwaaacnorgviewpoint


Opportunities for theUninsured to AccessAffordable Health Insurance and Care

There continues to be marked confusion about the sta-tus of the Affordable Care Act (ACA) that was passed in2010 The Republicans in the US Congress have tried torepeal the ACA more than 40 times and their efforts havebeen unsuccessful Staunch conservatives have ramped uppressure on Republicans in Congress and the Senate tomake efforts to repeal the ACA before its major provisionsgo into effect in 2014 The results of so many ACA repealsound bites have many Americans thinking the ACA hasbeen repealed and consequently some may not have beenusing or seeking benefits such as private insurance throughstate insurance exchanges Some say conservatives arehighly concerned that the ACA will be successful providinghealth care access and in cutting costs thereby creating sat-isfaction with the ACA among voters This could be a majorissue in the 2016 presidential campaign The ObamaAdministration has begun to do public service announce-ments and Webcasts to enhance Americansrsquo understandingof what the benefits of the ACA are and how they canobtain them Many are concerned that these efforts are toolittle and coming too late in the game

Ambulatory care nurses and other providers in ambula-tory care settings need to be conversant on both ACA ben-efits and how to access and use the state-based insuranceexchanges Private foundations such as the Kaiser FamilyFoundation (KFF) have designed their Web sites for ease ofuse and provide many up-to-date issue briefs slide setsvideos and analyses that will be summarized in this col-umn The KFF document ldquoAn Early Look at Premiums andInsurer Participation in Health Insurance Marketplaces2014rdquo (Cox Claxton Levitt amp Khosla 2013) providesinsurance information and tables that spell out actual costsand cost savings for persons with low incomes

The ACA provisions provide the opportunity for individ-uals and families to purchase private insurance coveragethrough new state-based exchanges also calledldquoMarketplacesrdquo which opened in October 2013 and offercoverage beginning January 1 2014 Some states haveopted not to set up their own exchanges and in thesestates the federal government will either run the exchangeor work in partnership with the state to create an exchangeldquoRegardless of whether an exchange is state-run or federal-ly facilitated enrollees with family incomes from one to fourtimes the federal poverty level (about $24000 to $94000for a family of four) may qualify for tax credits that willlower the cost of coverage through reduced premiums andin some cases also be eligible for subsidies to reduce theirout-of-pocket costsrdquo (Cox et al 2013 p 1) The KFF report

looks at insurer participation and exchange premiums ndashboth before and after tax credits ndash for enrollees in 17 statesplus the District of Columbia that have released data onrates or the rate filings submitted by insurers (Cox et al2013) Of those presented 11 states operate their ownexchanges and seven have a federally facilitated exchange

In January 2014 the ACA will provide three major ben-efits private insurance at affordable prices a ban on annu-al limits for coverage and coverage for those with pre-exist-ing conditions Plans offered in the state exchanges as wellas insurance coverage sold to individual and small business-es outside the exchanges must meet several new regulato-ry requirements (FernandezCongressional ResearchService 2011) The ACA provisions state that insurers mustcover a minimum set of services called ldquoessential healthbenefitsrdquo At a minimum essential health benefits ldquomustinclude ambulatory patient services emergency serviceshospitalization maternity and newborn care mentalhealth and substance use disorder services (includingbehavioral health treatment) prescription drugs rehabilita-tive and habilitative services and devices laboratory servic-es preventive and wellness and chronic disease manage-ment and pediatric services (including oral and visioncare)rdquo (FernandezCongressional Research Service 2011 p2) Further insurance carriers must organize plan offeringsinto five levels of patient cost sharing (catastrophic bronzesilver gold and platinum ranging from least to most pro-tective) Insurers will only be able to vary premiums by age(to a limited extent) tobacco status geographic regionand family size (Cox et al 2013)

The KFF (Cox et al 2013) explains considerations thatimpact cost of an insurance premium and offers examples oftypical premiums Bronze plans cover 60 of health carecosts when averaged across all enrollees have the most costsharing and therefore represent the lowest level of cover-age available through exchanges Consequently bronzeplans typically have the lowest premiums they vary signifi-cantly across geographical areas and by age but are also sig-nificantly reduced by subsidies for low-income populationsCatastrophic plans will be sold on the state exchanges butwill only be available to people who are under 30 years ofage or would have to spend more than 8 of their house-hold income on a bronze plan (Cox et al 2013)

What impact will state insurance exchanges have onpremiums for individuals and families who do not qualityfor subsidies A recent New York Times article highlightsldquoState insurance regulators say they have approved rates for2014 that are at least 50 lower on average than thosecurrently available in New York Beginning in October indi-viduals in New York City who now pay $1000 a month ormore for coverage will be able to shop for health insurancefor as little as $308 monthly With federal subsidies the costwill be even lowerrdquo (Rabin amp Abelson 2013)

View health care reform resources online atwwwaaacnorghealth-care-reform


WWWAAACNORG 13

Tobacco use still remains the number-one cause of pre-ventable disease in the United States with one out of fiveAmericans currently using tobacco products The thirdThursday in November was the Great American Smokeoutsponsored by the American Cancer Society However thedecision to quit smoking does not have to be limited to oneday For a full set of resources including table tents postersor other supplies to share with your patients visithttpwwwcancerorghealthystayawayfromtobaccogreatamericansmokeouttoolsandresourcesindex

Pre-diabetes is becoming epidemic in all age groups Foradditional information on diabetes risk factors screeningsand weight loss and dietary suggestions refer to materialsfrom the National Diabetes Prevention Center (in bothEnglish and Spanish) at httpdiabetesniddknihgovdmpubsprediabetes_ESPre_Diabetes_EN_SP_508pdf

Alzheimerrsquos disease and other dementias are often calledldquothe forgetting diseaserdquo When family members need extrasupport on how to cope with the family member who hasdementia direct them to the Alzheimerrsquos Association Website (httpwwwalzorgappsfindusasp) to find local sup-port groups

Gastroesophageal reflux disease (GERD) can cause symp-toms of burning irritation and heartburn To help toexplain the symptoms and treatment for GERD refer yourpatients to the MedlinePlus tutorial they can watch online(httpwwwnlmnihgovmedlineplustutorialsgerdhtmindexhtm)

Carol Ann Attwood MLS AHIP MPH RNC is a MedicalLibrarian Patient Health and Education Library Mayo ClinicArizona Scottsdale AZ She can be contacted atattwoodcarolmayoedu


Charlene Morris MSNED RNis the Coordinator for SupplementalStaffing at Virginia CommonwealthUniversity Health Systems inRichmond Virginia and supportsover 70 ambulatory care practicesShe trains and supervises staff toensure that competent and skillednurses provide excellent care topatients and families in their variouscomplex clinics

As a new AAACN member thisyear Charlene has realized that the strength of AAACN is itsknack for developing leaders while maintaining ongoingsupport of their delivery care model in ambulatory careAAACN and its leaders strongly embrace nurse empower-ment and autonomy through its values She is scheduled totake the ambulatory care certification exam shortly and hasbeen reviewing the Core Curriculum for Ambulatory CareNursing and the Scope and Standards of Practice forProfessional Ambulatory Care Nursing ndash these have beenresources for practice and her upcoming certification

According to Charlene what she likes most aboutworking in ambulatory care is ldquoliving the important transi-tions of cultural diversity and partnerships between thenurses family community and health care providers toensure that the best and most accessible care is providedrdquo

Her job satisfaction is stimulated by the positive feed-back from patients families and research that provides evi-dence-based support to bring about change and betteroutcomes This positive feedback also enhances staff satis-faction with their peers and colleagues

Charlenersquos biggest challenge as a nurse is staffing herorganizationrsquos complex high-volume clinics She is respon-sible for finding the right staff mix to achieve effective out-comes while supporting their multidisciplinary teamsSelecting the proper staff mix requires assurance of compe-tency and training She is also challenged to create the beststaffing plan that helps to reduce nurse burn out and dissat-isfaction in the workplace

On a personal note Charlene enjoys spending timewith her 16-year-old son family and community Sheenjoys reading watching her son play basketball and par-ticipating in community outreach Her future plans are tobegin teaching in spring 2014 as a nursing instructor at acommunity college Teaching full-time and working as alegal nurse consultant is her ultimate goal as she continuesto grow and learn in her current leadership role

Deborah A Smith DNP RN is an Associate Professor GeorgiaRegents University (formerly Georgia Health SciencesUniversity) College of Nursing Augusta GA and Editor of theldquoMember Spotlightrdquo column She can be contacted atdsmith5gruedu

Charlene Morris

There are several other resources available on Web sitesThe US Department of Health and Human Services(DHHS) (2013) offers on its Web site the opportunity toclick on a state to learn about current insurance statisticsand benefits available KFF (nd) offers a subsidy calculatorthat can assist patients with determining what level of sub-sidy they may qualify for when purchasing health insuranceat a state insurance exchange The National Association ofInsurance Commissioners (2010) offers on its Web site anexcellent set of frequently asked questions (FAQs) by con-sumers and employers with very concise answers This FAQsite can be used as a resource to inform providers and beshared with patients and families Ambulatory care nursesare only too aware of the need for reasonably priced healthinsurance for patients and families The United States final-ly has an Act the ACA that offers the opportunity for accessto health insurance and health care but we must do muchmore to spread the word and assist patients and familieswith this new opportunity

Sheila Haas PhD RN FAAN is a Professor Niehoff School ofNursing Loyola University of Chicago Chicago IL She can becontacted at shaaslucedu

ReferencesCox C Claxton G Levitt L amp Khosla A (2013) An early look

at premiums and insurer participation in health insurance mar-ketplaces Retrieved from httpkaiserfamilyfoundationfileswordpresscom201309early-look-at-premiums-and-participation-in-marketplacespdf

FernandezCongressional Research Service (2011 January 3)Grandfathered health plans under the Patient Protection andAffordable Care Act (PPACA) Retrieved from httpassetsopencrscomrptsR41166_20110103pdf

Kaiser Family Foundation (KFF) (nd) Subsidy calculator Premiumassistance for coverage in exchanges Retrieved fromhttpkfforginteractivesubsidy-calculator

National Association of Insurance Commissioners (2010) Healthcare reform frequently asked questions (FAQ) Retrieved fromhttpwwwnaicorgindex_health_reform_faqhtm

Rabin RC amp Abelson R (2013 July 16) Health plan cost forNew Yorkers set to fall 50 New York Times Retrieved fromhttpwwwnytimescom20130717healthhealth-plan-cost-for-new-yorkers-set-to-fall-50html

US Department of Health and Human Services (DHHS) (2013)How the health care law is making a difference for the people ofIllinois Retrieved from httpwwwhhsgovhealthcarefactsbystateilhtml

Health Care Reformcontinued from page 12

Core Curriculum forAmbulatoryCare NursingThird Edition

Candia Baker Laughlin MS RN-BCEditor

Available nowThe Core Curriculum for AmbulatoryCare Nursing (3rd ed) is for sale inthe AAACN online store Memberssave $20 and can earn over 30 FREEcontact hours See wwwaaacnorgcore for details

WWWAAACNORG 15

situation like yours often find it helpful tohelliprdquo This normal-izes the situation somewhat so that the woman knows sheis not the only person to experience domestic violence andthat help is available It is important to not divulge details ofyour own experience because this is a professional settingand your job is to offer validation and resources

Guiding Your Caller to HelpAs you assess patients throughout your workday listen

for the question behind the question the caller may be ask-ing you Remember that while abuse may be clear to youthe victim is often slow to identify it or admit it The path torecognition of abuse is often long and winding for the vic-tim However if we recognize it we must be prepared tooffer emotional support and resource options We may notbe able to rescue victims of domestic violence but we canmake every attempt by directing them to avenues of sup-port which may lead to escape from the situation

ReferencesCenters for Disease Control and Prevention (CDC)

(2013) Intimate partner violence Retrieved from httpwwwcdcgovviolencepreventionintimatepartnerviolence

Minsky-Kelly D Hamberger LK Pape DA amp Wolff M (2005)Wersquove had training now what Qualitative analysis of barriersto domestic violence screening and referral in a health caresetting Journal of Interpersonal Violence 20(10) 1288-1309

National Coalition Against Domestic Violence (NCADV) (2007)Domestic violence facts Retrieved from httpwwwncadvorgfilesDomesticViolenceFactSheet(National)pdf

Kathleen Swanson BSN RN is Adjunct Faculty in a practicalnursing program She is currently enrolled in the Doctor ofNursing Program at the University of Minnesota in the special-ty of Health Innovation and Leadership She has personalexperience as a victim of domestic violence

Telehealth Trials amp Triumphscontinued from page 3

ViewPoint is initiating a designated column toaddress targeted safety topics called ldquoSafety CornerrdquoThe column will be limited to 1000 words (about 2pages when published) Evidence-based strategies thatyou use to address actual or near-miss events should bethe focus Keep it simple as you describe the safety topicyou are passionate about sharing Please include whowhat when where and why this is applicable to ambu-latory as well as how to monitor effectiveness of the ini-tiative

For our official ldquoSubmission Tipsrdquo check out theViewPoint page on the AAACN Web site (wwwaaacnorgviewpoint) Share your questions ideas orsubmissions with Sarah Muegge MSN RN atSarahMueggecoxhealthcom

ReferenceInstitute of Medicine (2004) Keeping patients safe Transforming

the work environment of nurses Washington DC NationalAcademy Press Retrieved from httpwwwiomeduReports2003Keeping-Patients-Safe-Transforming-the-Work-Environment-of-Nursesaspx

Sarah Muegge MSN RN is an Instructor Regional ServicesCoxHealth Springfield MO and a member of the ViewPointManuscript Review Panel She can be contacted via email atsarahmueggecoxhealthcom

Order your copy nowaaacnorgreviewqs

Ambulatory Care Nursing Review Questions

bull Prepare for theambulatory carenursing certificationexam

bull Test your knowledgewith 179 multiple-choice questions

bull Score your answersbull Identify areas for

further study

Member Price $34 Regular Price $44

So long exam

stress

Providing health care is a complex process involvingthe patient his or her family and a team of health careprofessionals Although everyone strives to provide safehigh-quality care the best intentions can often fall shortof this goal It is not a matter of ldquoifrdquo you will commit amedication error misdirect a lab report that delaysappropriate treatment or fail to intervene before an at-risk patient falls and suffers injury It is a matter ofldquowhenrdquo it will happen to you

Nearly a decade ago nurses were recognized as anintegral component of maintaining a safe patient careenvironment within health care organizations (Institute ofMedicine 2004) Unless aligned to large organizationsthat designate staff and resources to monitor and reportsafety issues ambulatory care nurses may feel they areldquoon their ownrdquo to promote safety While recognizing theneed to share safer care initiatives with a wider audiencethan their own setting the time or perceived expertiserequired to publish a full article may seem overwhelming

Presorted StandardUS Postage

PAIDDeptford NJPermit 142

CHANGE SERVICE REQUESTED

Volume 35 Number 6

East Holly Avenue Box 56Pitman NJ 08071-0056

AJJ-1013-V-17C

copy Copyright 2013 by AAACN

AmbCareNursing

wwwfacebookcomAAACN

ViewPoint is published by theAmerican Academy of Ambulatory

Care Nursing (AAACN)

AAACN Board of Directors

PresidentSusan M Paschke MSN RN-BC NEA-BC

President-ElectMarianne Sherman MS RN-BC

Immediate Past PresidentSuzi Wells MSN RN

DirectorSecretaryJudy Dawson-Jones MPH BSN RN

DirectorTreasurerCarol A B Andrews Col USAF NC PhD RN-BC NE-BC CCP

DirectorsDebra L Cox MS RNNancy May MSN RN-BCCAPT (Ret) Wanda C Richards MPA MSM BSN

Executive DirectorCynthia Nowicki Hnatiuk EdD RN CAE FAAN

Director Association ServicesPatricia Reichart

AAACN ViewPointwwwaaacnorg

EditorKitty M Shulman MSN RN-BC

Editorial BoardSharon Eck Birmingham DNSc MA BSN RNPatricia (Tricia) Chambers BHScN DC RNVirginia Forbes MSN RN NE-C BCLiz Greenberg PhD RN-BC C-TNPPatricia L Jensen MSN RN

Manuscript Review PanelRamona Anest MSN RNC-TNP CNEDeanna Blanchard MSN RNAmi Giardina MHA BSN RNJennifer Mills RNC CNS-BCSarah Muegge MSN RNBCVannesia D Morgan-Smith MGA RN NE-BCBecky Pyle MS RN B-CPamela Ruzic MSN RN-BCAssanatu (Sana) I Savage PhD DNP FNP-BCLaurel Stevens MSN RN NEA-BCJanice S Tuxbury DNP FNP-BC

Managing EditorKatie R Brownlow ELS

Editorial CoordinatorJoe Tonzelli

Layout DesignerBob Taylor

Education DirectorRosemarie Marmion MSN RN-BC NE-BC

Marketing DirectorTom Greene

Through AAACNrsquos affiliation with theNational Council State Boards of Nursing(NCSBN) Nurse Licensure Compact Coali -tion members Kathleen Damian RN andTami Regan RN CHT testified at theMassachusetts State House on October 29 infavor of the Nurse Licensure Compact (NLC)Representatives from the MassachusettsHospital Association Lahey Hospital andMedical Center Cambride Health Allianceand Organization of Nurse Leaders (MA andRI) also gave strong and compelling testimo-ny in favor of the compact The NationalMilitary Families Association sent a letter toeach member of the Joint Committee sup-porting the NLC legislation Opposing testi-mony came from the President of theMassachusetts Nurses Association

Kathleen said ldquoIt was a wonderfulopportunity to educate our legislators aboutthe actual nuts and bolts of caring forpatients telephonically and the Massa -chusetts regulation governing nursing prac-tice using telecommunications technologyrdquo

A vote was not taken at the hearingNext steps for the legislation will beannounced in the future AAACN has urgedour MA telehealth nurse members to con-tact members of the Joint Committee onPublic Health to tell them why the NLC leg-islation is important to them

AAACN is a welcoming unifying community for registered nurses in all ambulatory care settings Our mission is to advance the art and science of ambulatory care nursing

Members Testify in Massachusetts in Favor Of the Nurse Licensure Compact

Stuart Pologe COO Night Nurse and AAACNmember Tami Regan

IAAACNrsquos Core Business ndash

LeadershipGreetings from your Board of Directors

In this Presidentrsquos Message I have the pleasure of giv-ing you an update from the SummerFall Board of DirectorsMeeting held in August at the National Office in PitmanNew Jersey It was a wonderful opportunity to work togeth-er with colleagues in person rather than our usual monthlytelephone conference calls We did a lot of work and bal-anced that with a lot of fun as well

AAACN is involved in a multitude of initiatives and proj-ects in addition to our everyday activities The RN CareCoordination and Transition Management (RN-CCTM) CoreCurriculum is in process Author teams are busy completingthe chapters that represent each of the nine core dimen-sions of care coordination identified by the previous expert panels Publication ofthe Core is expected in mid-2014 We will soon being developing the RN-CCTMcourse consisting of online education modules

We are considering a collaborative effort with a credentialing organization tooffer an exam that would provide a ldquocertificaterdquo to the person completing thecourse A certificate is an attestation that one has completed the coursework andpassed an exam This is not a certification which would include additional creden-tials after onersquos name but could possibly be the first step toward a certification inthe future Further discussion is needed prior to final decisions being madeContinued updates will be available in future Messages

The Ambulatory Care Certification Review Course (CRC) is taking on a new lookndash it will be offered as part of the Intensive CE Series from Gannett Education as anonline course consisting of four reading modules and five Webinars beginningearly next year The course is based upon the very successful CRC that has beenoffered over the past 13 years by AAACN We expect to continue to offer the ldquoliverdquoCRC at the AAACN Annual Conference and on demand Those interested inbecoming certified will now have four ways to prepare for the exam by taking ardquoliverdquo in-person course by purchasing the CRC DVD individually or as part of asite license in the Online Library or by participating in the online GannettAmbulatory Care Nursing Certification Intensive CE Series I am hopeful that withthese alternatives we will see an increase in the number of ambulatory certifiednurses in the near future

In preparation for the Board meeting members were asked to read Road toRelevance the sequel to Race for Relevance which we read last year Both bookspublished by the American Society of Association Executives offer organizationsthe opportunity to evaluate their relevance and value to their members and todetermine what will continue to keep them relevant in the future As a result webegan a discussion about the ldquocore businessrdquo of AAACN by asking ldquoWhat is ourmain focus or essential activity that sets us apart from other nursing and profes-sional organizationsrdquo The answer LEADERSHIP and Leadership Development

AAACN has developed nurses and leaders throughout its history ndash throughannual conferences networking and discussion groups development of stan-dards a core curriculum and a certification review course for ambulatory care andtelehealth Special Interest Groups (SIGs) continuing education scholarships andawards and numerous volunteer opportunities for personal and professionaladvancement However development of leaders does not happen on its own

As an organization we draw upon our core strengths and the areas in whichwe excel to promote leadership among all ambulatory care nurses The Board isreviewing the products services and programs AAACN provides in light of our


Reader ServicesAAACN ViewPointAmerican Academy of Ambulatory CareNursingEast Holly Avenue Box 56Pitman NJ 08071-0056(800) AMB-NURSFax (856) 589-7463Email aaacnajjcomWeb site wwwaaacnorg

AAACN ViewPoint is a peer-reviewed bi-monthly newsletter that is owned and pub-lished by the American Academy ofAmbulatory Care Nursing (AAACN) Thenewsletter is distributed to members as adirect benefit of membership Postage paid atDeptford 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 AAACNs newslet-ter Web site and other promotional and edu-cational materials

For manuscript submission informationcopy deadlines and tips for authors pleasedownload the Author Guidelines andSuggestions for Potential Authors availableat wwwaaacnorgViewPoint Please sendcomments questions and article sugges-tions to Managing Editor Katie Brownlow atkatieajjcom

AAACN Publications andProductsTo order visit our Web site wwwaaacnorg

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

SubscriptionsWe offer institutional subscriptions only Thecost per year is $80 US $100 outside USTo subscribe call (800) AMB-NURS or (856)256-2350

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

copy Copyright 2013 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 andor advertisers and donot necessarily reflect the views of AAACNAAACN ViewPoint or its editorial staff

Publication Management is provided by Anthony J Jannetti Inc which is accreditedby the Association Management Company

Institute

Susan M Paschke


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Volume 35 Number 6


AJJ-1013-V-17C


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WWWAAACNORG 3




















Kathleen Swanson






























FREE

WWWAAACNORG 5

















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Volume 35 Number 6


AJJ-1013-V-17C


AmbCareNursing

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FREE

WWWAAACNORG 5

















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B-12(n=28)

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Charlene Morris














WWWAAACNORG 15




















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stress






Volume 35 Number 6


AJJ-1013-V-17C


AmbCareNursing

wwwfacebookcomAAACN



























WWWAAACNORG 5

















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Hep B(n=1)

DTap(n=4)Zoster

(n=6)Epogen (n=1)

Zoladex (n=2)

B-12(n=28)

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20

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35

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WWWAAACNORG 7












































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Annually

10

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WWWAAACNORG 11












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WWWAAACNORG 13














Charlene Morris














WWWAAACNORG 15




















further study


So long exam

stress






Volume 35 Number 6


AJJ-1013-V-17C


AmbCareNursing

wwwfacebookcomAAACN















































Pneu

mon

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5

10

15

20

25

30

35

40

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WWWAAACNORG 7












































WWWAAACNORG 9















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Other

Every 2 years

Annually

10

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12



























WWWAAACNORG 11












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WWWAAACNORG 13














Charlene Morris














WWWAAACNORG 15




















further study


So long exam

stress






Volume 35 Number 6


AJJ-1013-V-17C


AmbCareNursing

wwwfacebookcomAAACN



























WWWAAACNORG 7












































WWWAAACNORG 9















98






Other

Every 2 years

Annually

10

78

12



























WWWAAACNORG 11












wwwlvmsystemscom



















WWWAAACNORG 13














Charlene Morris














WWWAAACNORG 15




















further study


So long exam

stress






Volume 35 Number 6


AJJ-1013-V-17C


AmbCareNursing

wwwfacebookcomAAACN













































WWWAAACNORG 9















98






Other

Every 2 years

Annually

10

78

12



























WWWAAACNORG 11












wwwlvmsystemscom



















WWWAAACNORG 13














Charlene Morris














WWWAAACNORG 15




















further study


So long exam

stress






Volume 35 Number 6


AJJ-1013-V-17C


AmbCareNursing

wwwfacebookcomAAACN





















































WWWAAACNORG 11












wwwlvmsystemscom



















WWWAAACNORG 13














Charlene Morris














WWWAAACNORG 15




















further study


So long exam

stress






Volume 35 Number 6


AJJ-1013-V-17C


AmbCareNursing

wwwfacebookcomAAACN






































WWWAAACNORG 13














Charlene Morris














WWWAAACNORG 15




















further study


So long exam

stress






Volume 35 Number 6


AJJ-1013-V-17C


AmbCareNursing

wwwfacebookcomAAACN



































Charlene Morris














WWWAAACNORG 15




















further study


So long exam

stress






Volume 35 Number 6


AJJ-1013-V-17C


AmbCareNursing

wwwfacebookcomAAACN



























WWWAAACNORG 15




















further study


So long exam

stress






Volume 35 Number 6


AJJ-1013-V-17C


AmbCareNursing

wwwfacebookcomAAACN






























Volume 35 Number 6


AJJ-1013-V-17C


AmbCareNursing

wwwfacebookcomAAACN



























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