Historically, the outpatient setting was the “professional home” of physicians.

They saw the

majority of their patients in their offices and referred them for other services or levels of care, as
needed. Registered nurses were few as the system was physician driven. However, fiscal caps for
hospital care and technological advances moved patients from inpatient venues into the ambulatory
care setting. Patients required higher levels ofcare than in the traditional outpatient settings, and
the ambulatory venue saw a growth in the number of professional nurses. Over the past 3 decades,
ambulatory care nurses have grown in number and in their ability to distinguish themselves as a
unique professional specialty. A definition of their practice and the development of a conceptual
framework are hallmarks of this distinctive professional progression.

Definition of Professional Ambulatory Care Nursing

Professional ambulatory care nursing is a unique domain of specialty nursing practice focusing on
health care for individuals, families, groups, communities, and populations. Ambulatory care
nurses practice in settings distinctive from other nurses. They practice in primary and specialty
care outpatient venues, non-acute surgical and diagnostic outpatient settings in the community,
and during telehealth nursing encounters that occur in centers, medical offices, or by individual
nurses in the home. Characteristics of ambulatory care nursing. Ambulatory care nursing is
characterized by registered nurses caring for high volumes of patients in short periods of time
(always less than 24 hours), often dealing with issues in each individual encounter that can be
unknown and unpredictable. Ambulatory care nurses address, in partnership and collaboration with
other health care professionals, patients’ wellness, acute illness, chronic disease, disability and
end-of-life needs. As nurses, they are responsible for patient advocacy, coordination of nursing
and other health services, implementation of nursing judgment and services, and continuity of care.
Ambulatory care nursing includes those clinical, organizational, educational, and research
activities engaged in by registered nurses for and with patients (individuals, groups, and
populations that seek carefor health-related problems and concerns or seek assistance with health
maintenance and/or health promotion). Patients in ambulatory care predominantly engage in self-
care and self-managed health activities or receive care from family/significant others outside
institutional settings. The nurse assists and influences the patient and/or caregiver in making
informed decisions about self-care and health behaviors.Ambulatory nurse-patient encounters.
Ambulatory care nursing services are episodic, and occur as a single encounter or a series of
encounters over hours, days, weeks, months, or years. Despite timelimited episodic encounters,
ambulatory care nurses generally have long-term relationships with patients, families, and
caregivers, teaching and translating collaborative plans of care into doable activities to meet health
needs. Ambulatory nurse-patient encounters take place in health care facilities, in telehealth
service situations, electronic communications, as well as in community-based settings, including
outpatient office systems, private medical offices, freestanding clinics, schools, workplaces, or
homes.

Conceptual Framework
The second hallmark of growth as a profession was establishing and then expanding the conceptual
framework for ambulatory care nursing. In 1998, American Academy of Ambulatory Care Nursing
(AAACN) expert members were called together in a “think tank” session to collaboratively
develop a conceptual framework for ambulatory nursing practice. Using a nominal group
approach, the members identified two major concepts that interplay in the specialty: “patient” and
“nurse.” In 2009, the AAACN membership revisited the original framework and decided an
expansion was relevant. The conceptual diagram (see Figure 1) extends the original 1998
framework and diagram, identifying three major concepts: (a) patient, (2) environment, and (3)
nurse. The framework was posted on the member web site, and the members of AAACN reviewed
and commented on the proposed changes. Over 85% of the members responding indicated
“environment” was critical to their practice and defining it was important. The members made
comments that were incorporated into the final framework statement.
Patient
Inherent within the concept of “patient” is each individual is unique; functions holistically as a
biological, psychosocial, and spiritual being; and is the center of patient-nurse interactions.
“Patients” in the ambulatory care setting refers to individuals, families, caregivers/support
systems, groups, and populations that approach the health system in a variety of circumstances or
health states. Patient health states are categorized as “wellness or health,” “acute illness,” “chronic
disease and/or disabled,” and “end of life.” Generally, patients initiate contact with the ambulatory
care system to meet their wellness concerns and health needs. Patients maintain control of the
encounter and treatment with the nurse acting in a consultative role.
Environment

The second concept, “environment,” helps define ambulatory nursing practice, setting it apart from
other nursing specialties. In addition to the nursepatient relationship and interactions, ambulatory
care nurses must address organizational, social, economic, legal, and political factors, both within
the health care system and also in the external health care environment. The internal care delivery
environment is where patients initially access and receive care and where the nurse actually
practices. The external environment refers to both the geographic locale of the specific health care
practice and contextual factors in the greater ambulatory care environment.

Internal care delivery environment.

The ambulatory nursing care delivery environment is dynamic and diverse, including a broad
scope of practice settings where patients seek health care treatment and where the professional
nurses function. The ambulatory nursing care delivery environment can include such settings as
an individual physician’s office, group office practices, freestanding or hospital-based clinics,
infusion centers, nursing clinics, ambulatory surgery or procedure centers, telehealth centers, care
coordination organizations (case, care, and disease management organizations), multispecialty
health organizations (e.g., health maintenance organizations), military bases, or comprehensive,
integrated health care systems.
External environment.

The external geographic locale and contextual factors often influence an individual ambulatory
health care setting’s mission, patient population, and practices. For example, rural and urban
outpatient settings most likely address different patient needs and have different requirements and
resources. The external contextual factors include, but are not necessarily limited to, the current
health policy, governmental laws, professional practice regulations, accrediting agency standards,
health care financing systems, and advances in science and technology. Emerging scientific
knowledge and diagnostic and treatment technologies as well as the information management
systems that support and coordinate patient care through virtual information exchange all influence
the practice of ambulatory care nursing significantly. Further, each health care delivery setting is
affected by general circumstances, such as socioeconomic conditions, cultural considerations,
safety, transportation, pollution, disasters, epidemics, and/or pandemics, etc.
Nursing

The third concept, “nursing,” defines professional ambulatory care nursing as a unique domain of
specialty nursing practice. It is characterized by professional nursing staff responding rapidly to
high volumes of patients in a short period of time, often dealing with issues that are unknown and
unpredictable. Nurse-patient encounters occur on an episodic basis, but relationships often last
months or years. The scope of professional ambulatory care nursing is dynamic, evolving
continually in response to changing societal and organizational needs and the expanding
knowledge base of ambulatory care nursing’s theoretical and scientific domains (American Nurses
Association, 2004). The research of Haas and Hackbarth (1995) helped delineate that ambulatory
care nursing may be categorized into three major roles: clinical, organizational/ systems, and
professional. While defined separately, these roles are not necessarily mutually exclusive and
frequently overlap. It is this overlap of roles that brings challenges and professional growth, adding
dynamism, learning, and diversity to ambulatory nursing practice. Clinical nursing role.
Ambulatory care nurses practice clinically by using the nursing process in their specific specialty
role. Clinical nursing, both in the clinic setting and when providing telehealth services, requires
expert nursing process skills: assessment of patient problems and concerns in limited time frames;
the ability to critically analyze and integrate subjective and objective data related to patient
concerns and conditions; capabilities to identify problem (s) and pertinent goals; competence in
planning appropriate nursing care; the ability to implement suitable, evidence-based nursing
interventions; and appropriate evaluation of patient outcomes. The ambulatory care nurse also
applies the nursing process in assessing, analyzing, planning, delivering, and evaluating care of
patient groups and populations.
The clinical role activities also encompass:
1. Patient advocacy
2. Compassion, caring, and emotional support.
3. Sensitivity to the patient’s cultural, ethnic, and age-related needs.
4. Referral of patients to optimal health services.
5. Education and support of self-care behaviors to promote health and prevent disease and
secondary complications.
6. Performance of nursing procedures.
 7. Consultation and collaboration with professional colleagues.Careful, complete
documentation of care given.
8. Management of clinical nursing care and practices and their outcomes.
Inherent in the clinical role is the use and development of appropriate, evidence-based
nursing knowledge and health care protocols.
Organizational/systems role.
Ambulatory care nurses practice within the organizational/systems role when they
administer and coordinate resources and direct clinical and organizational activities and workflow
within their health care setting. The organizational role has multiple dimensions: staffing,
workload and competency concerns, workplace regulatory compliance and risk management,
health care fiscal management, legal and regulatory issues, organizational cultural competence,
quality management systems, the application of health informatics systems, use of diagnostic and
treatment technologies, conflict management, structuring customerfocused systems, and patient
and health advocacy within the organization and across the community.
Professional role.
Ambulatory care nurses function within the professional role as they practice according to
professional, ethical, and organizational standards. The professional role also requires the use of
evidence-based techniques, the evaluation of the outcomes of nursing practice, the lifelong
expansion of ambulatory nursing knowledge and skills of self as well as contributing to that of
other staff, contribution to the advancement of the nursing profession and the specialty, and the
continuous improvement of the quality of health care practices and outcomes. As professionals,
ambulatory care nurses are expected to demonstrate leadership skills within the health care
organization, in the community, and across the nursing profession. While some aspects of all three
roles are part of every ambulatory care nurse’s practice, emphasis on one of the roles usually exists
depending on the specific role and position of the nurse within the practice setting. For example,
the telehealth services and clinical nurses will most likely focus largely on the clinical role
requirements of their job descriptions, but organizational (unit workflow concerns) and
professional role requirements (education or research) may also be expected depending on the
organization’s structure and the unique situation. The requirements for quality nursing care in
ambulatory settings have expanded and will continue to do so. But ambulatory nurses, with the
support of AAACN, their professional organization, have demonstrated their ability to advance,
articulating their professional practice theoretically and conceptually as well as in practice
interventions.