Open Forum

Hello,

I am working on an EBP project where we are working to establish Best Practices for Ambulatory RNs for Top-of-License work. We are currently assessing current clinic staffing models and what tasks (or roles) RNs are completing throughout the day. I am wondering if anyone here is able to give me a general idea of how many RNs are in your specific clinics and examples of tasks that they do throughout the day? Are your RNs typically "procedural" or are the tasks more related to "care management"? 

Any insight you can provide would be helpful!

Thank you!

Savannah

Savannah,

Hello!  We have done some work to define "Top of Scope" work for RNs both in-person and remote/ centralized.  At this point we have focussed mostly on Primary Care. 

Attached is a snapshot of this work.

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ShawnaSharpCommonSpirit HealthSystem Director Clinical Transformationshawna.sharp@commonspirit.orgCA
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Hi Savannah - 

We're a specialty pediatric pulmonology clinic and have 4 nurses per day, and a severe asthma nurse part-time for biologics and the comprehensive asthma management program. We primarily see asthma and cystic fibrosis patients but also have a home ventilator and biologics clinics and see BPD as well. We have clinic 1/2 day Monday and all day the rest of the week. Numbers range from 8 patients in a half day to around 40 patients on a full day with 6 physicians. We split nursing depending on the clinic needs, 1 RN in clinic to 1-3 MDs depending on the visit type (NP, RV, BPD, Vent, CF). 

Phone Nurses do phone triage, sick call management (red call heavy clinic due to severe pulm diseases), med refills, equipment ordering and management, education over the phone, care management. One nurse does a weekly pre-clinic interprofessional huddle for all CF patients (1hr) and weekly post-clinic huddle (1hr) for CF as well.

In clinic, RNs do med rec on CF only, to assess for knowledge and adherence, but we have a pharmacist for CF, so skip this if she already did it, which is often. RNs do CF throat cultures, educate and guide caregivers through the first administration of biologics, asthma and biologics education (some are AE-Cs), CF education through the lifespan including specific transition readiness modules from CFRISE.com, CF and asthma action plan creation and education, orders for CF that are under protocol (annual labs, XRay, etc), direct admission set-up (calling admitting, filling in the template used to communicate the plan to the inpatient team, preparing patients), and help with interprofessional communication, since all these clinics have MD, SW, psychology, PT, RT, RDN, etc. Nurses also manage nurse billing and they create education materials based on the needs of the population. They also are involved in quality improvement meetings and projects depending on the topic. Sometimes we help busy RTs give albuterol for post-bronchodilator spirometry, but not often. 

They have been working for a while to work at top of scope. Paperwork (there is a ton of FMLA and home care order reconciliation in our clinic) and prior auths have been given to non-licensed personnel. We're specialty, so don't do a lot of Imms, but flu shots are done by MAs. Med rec in clinic used to be all RNs but has moved to MA except with CF for education reasons (at our request). Vitals and rooming are MAs, of course. 

We're education heavy, especially with the chronic patients that we see, then care management, with procedural being there (cultures and biologics) but not heavy. 

Best, 

Cathy

Catherine Enochs, MA, BSN, RN
Pediatric CF Program Coordinator
University of Michigan Health

Good afternoon, Savannah, 

First, I am the only RN in my department, and we are a subspecialty, so my role is a bit unique. I was hired on as a clinical nurse and advised that my role was primarily "research" based, but that I would be helping to build this department when we opened five years ago. In addition to only one RN, we only have one senior CMA and one PSR for three providers (MD, NP, and GC) in my department, so I wear a lot of hats. I also have a lot of autonomy which allows me to practice to the top of my scope and thrive in my role. I review referrals for appropriateness, scan the providers schedules to ensure we have appropriate advance directives, consent forms are ready, and social work on standby as needed. The work I do is HEAVY in chart review and patient education. I help patients understand their genetic diagnosis, treatment, and provide care coordination across departments and with external tertiary center as needed both in-person and virtually.

We deal with genetic testing, specialty medications, and order various diagnostics. I ensure that the appropriate insurance coverage for these services is obtained, or that patients are enrolled in sponsored programs. There are times I will engage in peer-to-peer discussions with physician reviewers or write appeal letters (except for Medicare denials). Our patients have various concerns, with complex genetic conditions and so triage is also a part of the daily work I do. We have a senior CMA that does the majority of rooming (vitals, allergy & med reviews), as well as buccal sample collection in the office, however, I do a fair amount of this as well when we are busy or the event that we have a call in with no float coverage. Our senior CMA also does refill medications, except for specialty meds or those requiring titration and/or triage which are left to the RN. I keep the education board with printed material up-to-date and facilitate our weekly team huddle to discuss patient concerns, workflow issues, and any upcoming absences so we can plan accordingly. The results from genetic testing done through our external lab vendors go to our CMA and everything is scanned/on-based immediately in our EMR, then messages are sent to the RN in basket to ensure appropriate follow-up.

Another big part of my role as an educator is to help create educational materials and department protocols for Genetics. I have created these protocols and review these annually with my 1-up for any needed updates. I also participate in speaking/education events within my organization as well as journal club discussions with the ambulatory float nurse group which looks at topics relevant to our practice with an EBP scope. 

Finally, the geneticist I work with in my department is only in the clinic 3 days a week (2 days at the research lab at the U of I). We have a patient registry for our connective tissue clinic, and I am the study nurse for any clinical trials we do here. I help with recruitment, printing study/consent materials, patient screening, rooming patients, administering lidocaine w/epi for bunch biopsies and collecting other specimens as needed. I provide wound care education and follow-up, participate data collection, working with our Quality department for PI/EBP projects. I am currently working with our research department on an abstract for screening tool comparison study that I hope to start this fall for the multidisciplinary clinic that we hold once monthly for EDS/hypermobility, and I hope to publish our findings in a nursing journal and/or discuss at a magnet conference in the future. 

Thank you, 

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Christina Goode, BSN, RN, AMB-BC
Nurse Educator
Adult Genetics, Carle Health
Champaign-Urbana, IL

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