Systematically collects or supervises the collection of focused data related to health needs and concerns of a patient, group, or population.
Establishes a therapeutic rapport with patient and caregivers as well as determine the patient’s perception of his or her immediate needs or concerns
Identify barriers to providing optimal care (e.g., language, culture, and behavioral health issues)
Collect or validate the collection of subjective and objective health data from multiple primary and secondary sources
Use applicable evidence-based assessment techniques and instruments related to ambulatory care nursing in collecting pertinent patient or population data
Prioritize data collection activities based on the patient's, group's, or population's immediate health need or the nurse's clinical expertise of anticipated patient needs
Synthesize available data, information, and nursing knowledge relevant to the presenting health situation to identify patterns and variances as well as gaps in care
Prioritize the data and information collected based on the patient's or population's condition and preferences, situation, and/or anticipated needs
Document the information and data collected in a retrievable, understandable, and readable format
Reassess the patient and situation as needed to address alterations in health status
Analyzes the assessment data to determine the diagnostic statements for health promotion, health maintenance, or health-related problems or issues.
Identify the diagnoses, actual or potential, based on the analysis of assessment data and information, current ambulatory care RN knowledge, and evidence- based practice(s)
State the diagnoses using standardized language, and understandable and recognized terminology utilizing clinical decision-support tools
Validate the diagnoses and/or issues with the patient, caregivers, and other members of the interprofessional health care team when appropriate
Prioritize the diagnoses based on the patient's condition, expectations and preferences, situation, cultural and age-specific considerations, and/or anticipated needs
Document clearly the diagnoses to facilitate the determination of expected outcomes and plans
Identifies expected and/or desired outcomes in a plan of care individualized for a specific patient, group, or population.
Derive expected outcomes from the diagnosis(es)
Involve the patient, family, and health care team in formulating measurable expected outcomes
Consider associated risks, benefits, costs, current scientific evidence, and clinical expertise when formulating measurable expected outcomes
Define expected outcomes in terms of the patient values, preferences, spiritual, emotional, cultural, and ethical considerations, age-related issues, and situational environment
Develop measurable expected outcomes that provide direction(s) for continuity of care
Modify measurable expected outcomes based on changes in the status of the patient or reevaluation of the plan of care
Develops a plan that identifies strategies and alternatives to attain expected outcomes in individuals and/or populations.
Develop an individualized ambulatory care nursing plan for patients seeking care for health promotion, health maintenance, or health-related situational problems
Apply current ambulatory care nursing knowledge and evidence-based nursing practices in the plan of care
Include the patient, family, or caregivers as appropriate and the health care team in making shared decisions about prioritizing plans and strategies
Consider patient or population needs in terms of age, gender, race, cultural values and practices, ethical and legal considerations, environmental factors, and the anticipated risks and benefits of interventions for individualized plan development
Incorporate a timeline for ambulatory care nursing plan implementation and goal achievement, reevaluation or reassessment, follow-up care, and care coordination as appropriate
Consider the economic impact of the plan on patient and family resources
Document the plan and the patient's progress to ensure continuity of care using recognized terminology
Provide a plan of care that is clear and understandable to patient, family, and/or caregivers
Enacts the identified plan of care.
Prioritize interventions based on the patient's health status, preferences, resources, motivation, and anticipated needs
Facilitate the implementation of the interprofessional plan of care in partnership with the patient and caregivers in a safe, efficient, and timely manner
Utilize the unique knowledge, skills, and competencies required in ambulatory care nursing practice to promote wellness, restore health, and support end-of-life care
Utilize evidence-based, ambulatory care-specific interventions to achieve agreed upon outcomes during clinical visits, telephone encounters, and electronic communications according to state regulations, regulatory agency standards, and appropriate organizational policies and procedures
Document nursing interventions and services provided in the patient record, including modifications, changes, or omissions of the identified plan
Advocate for the health needs of individuals and diverse populations across the lifespan and the continuum of care.
Coordination of Care
The RN practicing care coordination and transition management (CCTNI®) coordinates the delivery of care within the practice setting and across health care settings.
Utilize an interprofessional approach to engage patient, caregivers, and providers in implementing the plan of care across care settings
Facilitate the transition of patient/populations to the appropriate level of care
Educate and activate patient and caregivers for optimal disease management by promoting healthy lifestyle changes in the prevention of illness across population(s)
Manage high-risk individuals and/or population(s) with the aim of preventing or delaying adverse outcomes
Apply effective teamwork and collaboration skills to overcome identified barriers to produce quality and effective patient outcomes
Health teaching and health promotion
Employs educational strategies that promote individual, community, and population health and safety.
Assess a group or patient's learning needs, abilities, readiness, preferences, and barriers to learning
Utilize health teaching and health-promotion strategies which support the patient's learning needs, values, preferred language, socioeconomic status, cultural, and spiritual preferences
Assure patient and caregivers understand intended outcomes and potential risks related to the plan of care
Address and reinforce the patient's age-specific and developmental needs related to plan of care
Support patient and caregivers in developing skills for self-efficacy to promote, maintain, or restore health, such as healthy lifestyles and risk-reducing behaviors
Continuously evaluate learner comprehension and effectiveness of teaching strategies and nursing interventions based on feedback from patient, caregivers, and health care team
Document learner assessment, comprehension, and effectiveness of educational strategies, as well as modifications to plan of care, based on patient feedback and progress toward identified outcomes
Promote and practice healthy self-care activities and stress management strategies and advocate for organizational policies and programs that promote a healthy workplace environment
Adheres to the current AAACN Scope and Standards of Practice for Professional Telehealth Nursing in all practice environments.
Coordinate interprofessional services across the care continuum
Provide efficient, effective, and evidence-based care within the telehealth services framework
Apply principles of ergonomics and safe work settings
Provides consultation in developing interprofessional plans of care, enhancing the ability of other professionals and effecting change.
Synthesize clinical data and best practices when providing consultation across the care continuum
Consult with appropriate stakeholders
Evaluates progress toward attainment of stated outcomes.
Conduct, systematic, ongoing, and criteria-based evaluation of patient and/or population outcomes prescribed by the plan of care and the indicated timeline
Include patient, caregivers, and all others involved in the care of the patient in the evaluation process
Consider patient and family values, preferences, socio-economic, political, religious, cultural, and environmental factors in evaluating the expected outcomes of the plan of care
Document patient status, evidence of patient and family participation and responses, including the rationale for revisions in plan of care
Communicate evaluation outcomes to patient, caregivers , and all other stakeholders as appropriate
The RN incorporates professional coded of ethics with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
Actively engage in addressing the ethical concerns of patients, colleagues, or systems through dialogue with nursing colleagues, managers, and interprofessional communication including members of the organizational ethics committee
Apply knowledge of principles contained in the American Nurses Association Social Policy Statement and Code of Ethics as evidenced by nursing care and professional interactions
Ensure patient care reflects the cultural, spiritual, intellectual, age, educational, and psychosocial differences of individual patients, families, groups, and communities
Disclose any observed legal or incompetent practices including decisions made by impaired health care (or potentially impaired) personnel to supervisory leadership, appropriate professional bodies, and reporting agencies
Educate and support patients developing skills for self-efficacy
Ensure patients have opportunities to voice opinions, without fear of recrimination, regarding care and services received, and to have these issues reviewed and resolved per organizational policy and regulatory guidelines
Demonstrate therapeutic interactions with patients and effective interactions with colleagues/staff while maintaining professional boundaries
Engage in activities that promote an ethical environment for the provision of patient care and interactions with co-workers
Use current research findings and other evidence to expand professional knowledge, enhance role performance, and increase knowledge of ambulatory care nursing professional issues
Demonstrate a commitment to lifelong learning through self-reflection and inquiry to identify learning needs
Promote the strength and effectiveness of the ambulatory care nursing profession through membership and active participation in professional and community organizations
Research and evidence-based practice
Participates in evidence-based practice initiatives and research activities to advance ambulatory care nursing and improve patient outcomes.
Utilize current research findings and other evidence to expand professional knowledge, enhance role performance, and increase knowledge of ambulatory care nursing professional issues
Identify clinical problems related to patient care delivery and/or ambulatory care nursing practice
Evaluate the research evidence using criteria for scientific merit and optimal application in clinical practice settings
Disseminate relevant evidence and research findings across organizational, community, and professional forums
Integrate evidence and research findings into clinical practice
Evaluate and reevaluate the outcomes of evidence-based interventions
Enhances the quality, efficiency, and effectiveness of clinical and professional nursing practice and organizational system.
Participate in the identification and definition of nurse-sensitive indicators
Lead and/or participate in quality and performance improvement initiatives within the organization and across the care continuum
Evaluate and disseminate the findings of quality and performance improvement initiatives
Implement evidence-based improvements into ambulatory care clinical, organizational, and professional practice
Foster an environment which encourages patients, families, caregivers, visitors, and staff to provide input for patient care improvement activities
Mitigate actual or potential risks to patient and staff safety
Communicates effectively using a variety of formats, tools, and technologies to build professional relationships and deliver care across the continuum.
Identify and evaluate personal skills and styles of communication to enhance effectiveness
Share ambulatory care nursing best practices with peers, requesting feedback and evaluation
Maintain professional communications with all members of the interprofessional health care team and other stakeholders
Communicate knowledge and skills acquired through formal and informal professional development activities
Demonstrates leadership behaviors in practice settings, across the profession, and in the community.
Demonstrate respect for the dignity, worth, and contributions of others
Acknowledge and learn from mistakes, taking remedial action as needed Recognize, address, and mitigate workflow inefficiencies
Proactively anticipate and recognize the needs of others, using positive interactions and creative solutions to achieve effective outcomes
Actively advocate for collegial, safe environments in ambulatory care clinical practice, organizational environments, and community settings
Assume responsibility and accountability for coordinating all aspects of the nursing process including delegated care
Collaborate with the interprofessional health care team to build and maintain an effective and dynamic professional relationship
Participate actively in organizational shared decision-making situations that improve ambulatory care nursing practice, organizational performance, and outcomes
Promote the continued growth, strength, and effectiveness of professional ambulatory care nursing through membership and active participation in professional and community organizations
Cultivate and sustain a culture of safety
Collaborates with patients, family members, caregivers, and other health professionals in the conduct of ambulatory care nursing practice.
Partner with patients, caregivers, other health care providers, and resource agencies to develop a documented plan of care that promotes positive patient outcomes
Use effective professional communication skills and tools to acquire and disseminate relevant information to patients, caregivers, and health care providers across the care continuum
Collaborate with colleagues to identify and rectify gaps in care and organizational inefficiencies to effect improved outcomes
Share knowledge and skills with peers and colleagues as evidenced by such activities as patient care conferences or presentations at formal or informal meetings
Professional practice evaluation
Evaluates his or her own and others nursing practice in relation to professional practice standards and guidelines, patient outcomes, organizational policies and procedures, and relevant governmental regulations and statutes.
Utilize ongoing and systematic evaluations of work processes and individual performance standards
Take action to achieve goals identified during the professional practice evaluation process
Use evidence-based rationale for practice decisions and actions as part of informal and formal professional practice evaluation
Engage in evaluation of self and other professional nursing staff to improve ambulatory care nursing practice
Engage in regular organizational performance reviews to identify strengths, opportunities for growth, and set performance goals and objectives
Use available organizational systems and tools to perform reviews and evaluation of ambulatory care nursing practice
Evaluate ambulatory care professional nursing practice based on use of independent nursing judgment, appropriate self-regulation, and accountability
Actively seek feedback regarding one's own ambulatory care nursing practice from patients, peers, professional colleagues, and others
Participate in department and organizational peer review, mentoring, and coaching regarding professional practice or role performance
Utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, and fiscally responsible.
Partner with patients and caregivers to identify patient needs and the resources available to achieve desired outcomes
Implement effective and cost-appropriate ways to maximize wellness, prevent illness, and manage acute and chronic diseases and disabilities to affect the best attainable health status over the patient's lifespan, up to and including a peaceful death
Delegate to appropriate members of the care team when RN level of care is not required, following applicable laws and regulations
Advocate for the patient and caregiver(s) to access appropriate and available resources to meet their health needs and concerns
Evaluate the impact of resource allocation on the potential for harm, complexity of the task, and desired outcomes
Educate and support the patient and caregiver(s) to become informed consumers about the options, costs, risks, and benefits of health care services