AMBULATORY BEST PRACTICES Challenging Misperceptions About ASC Nursing: My Story SARAH LOGUE, BSN, RN, CNOR, LHCRM
I
f you had asked me 10 years ago whether perioperative ambulatory nursing would be my career path, I would have laughed. I was a hardworking hospital perioperative nurse who circulated, scrubbed, and took call frequently, and I could not imagine how outpatient surgeries could compare with what I viewed as the life-changing and often life-saving procedures we performed every day in the hospital setting. At that time, I viewed outpatient surgeries as being mostly simple procedures, such as tonsillectomies and cataracts. My perception then was that “real” OR nursing took place only in the hospital setting. Although the demand for ambulatory services continues to increase in the United States, perioperative nurses may have incorrect perceptions about ambulatory care nursing. What follows is my experience in overcoming my perceptions about ambulatory care. The purpose of sharing my story is to help other perioperative nurses expand their outlook on ambulatory surgery center (ASCs) and the role of nurses in the outpatient setting. BACKGROUND After my husband underwent open heart surgery, our lives changed forever, and there were new personal matters to balance with professional obligations. Part of that change required us to move
from one area of the country to another. I began a new OR position in a hospital that had recruited me. This new hospital setting, however, did not fulfill my understanding and expectations of the job. In particular, I did not have the support that I had known in my previous nursing positions. Instead of being valued for my previous clinical experience, I had to start over and prove myself to a new set of physicians, anesthesia professionals, and fellow OR personnel. In addition, the interpersonal culture of the hospital OR was not ideal (eg, lack of support for a team concept in the OR, lack of valuing each team member as equally important). I felt pressured to circulate and scrub procedures that my colleagues did not want as well as to take more on-call shifts than others did. During the course of this experience I questioned what I believed about being a perioperative nurse. I realized that I needed to change not only my outlook on nursing but also my professional situation. NEW BEGINNINGS, NEW PERCEPTIONS While I was searching for a solution to my job situation, two surgeons who owned an ambulatory plastic surgery facility offered me the opportunity to broaden my OR skills in a unique waydby managing their ASC. These surgeons were in the process of bringing on two more board-certified
The AORN Journal is seeking contributors for the Ambulatory Best Practices column. Interested authors can contact the column coordinator, Debra Garton, by sending topic ideas to [email protected]. http://dx.doi.org/10.1016/j.aorn.2014.08.005
530 j AORN Journal
November 2014 Vol 100
No 5
Ó AORN, Inc, 2014
AMBULATORY BEST PRACTICES
www.aornjournal.org
imply that corporate-owned ASCs do not expeplastic surgeons, to allow them to meet their goals rience some of the same operational challenges of increasing the size of the center’s patient base and issues that small, single-specialty, physicianwhile remaining a single-specialty, physicianowned facilities encounter; however, transitionowned facility. I accepted the position because ing from the hospital setting to an ambulatory the surgeons convinced me that they valued the setting in which there are no other departments, entire team and that teamwork was how they resources, or mentors to help resolve an issue wanted to care for patients. was an eye-opening experience for me. Very quickly my new role began to challenge Another misperception of the ambulatory setting my perceptions of what it means to be an ASC is that there is little structure compared with the nurse. Instead of having a primary nursing focus, main OR setting. However, the opposite is true, as manager of an ASC, I assumed several roles, in particular with staffing plans and on-call strucsome that I had never performed before in the tures. My staff members and I are not required clinical setting. In addition to being the RN circuto work long days and then mandatory on-call lator for procedures, at other times, I was the preshifts. It is a rare thing for staff members to work operative or postoperative nurse. I scheduled a weekend shift, and personnel in the ASC I have developed a and in the physicians’ Transitioning from the hospital setting to an call tree for instances clinical practices. I ambulatory setting in which there are no other when a physician was a safety officer, departments, resources, or mentors to help needs to come into a quality assurance/ resolve an issue was an eye-opening experithe clinic on a weekprocess improvement ence for me. end. I have instituted specialist, licensed several flexible schedrisk manager, and an ules to accommodate infection prevention different staff member needs in the ASC and the nurse. I created policies and procedures, and was two clinical offices. I work diligently to cover all the go-to person for anything these documents of the responsibilities for various areas because I did not address. In addition, I came into the appreciate that the physicians never complain physicians’ clinics on weekends and after hours when I am out of the office. There have been when they needed to see patients. some weeks that I have worked 48 to 50 hours, This ASC was not part of a large management but these hours do not compare with the somecompany or owned by physicians in multiple spetimes 60 to 70 hours that I often worked in the cialties. Generally, small physician-owned ASCs hospital setting. have more financial and operational challenges Culturally, the ASC promotes teamwork and in terms of providing patient care and remaining supportive interpersonal dynamics. The physisolvent, unless the center performs eye, orthopedic, cians respected me from the outset, and I conor endoscopic surgery (ie, these procedures have tinue to feel valued for my input. Staff members a higher volume and easier turnover, which transreceive generous benefits that do not automatilates to higher revenue per OR minute). Comcally expire if unused. There are bonuses, and paratively, larger centers attached to corporations the benefit of working in a plastics facility with or hospitals have greater resources. For example, a medical spa. The facility has very little staff when setting up a new service or when working turnover, and I work with a terrific team. In on a necessary policy change, staff members at addition, working at an ASC has helped stabithese facilities have consultants or mentors who lize my work/life balance. can guide them through the process. This is not to AORN Journal j 531
November 2014 Vol 100
No 5
AMBULATORY BEST PRACTICES
peers who work in free-standing ASCs. In strugPROFESSIONAL GROWTH gling to manage several positions, please physiDeveloping a new outlook about what it means to cians and patients, and maintain a happy and be an ambulatory perioperative nurse has allowed well-adjusted staff, I have learned how to be me to grow professionally. I have learned so much more proactive as a team member and cultivate by working in an ASC. I have performed quality leadership skills that I never would have had the improvement studies by using unique approaches opportunity to develop in my previous nursing to address an issue (eg, being solely responsible positions. for determining a need and for devising and imIn my ASC, I also had the privilege of watchplementing a strategy to meet that need; identiing two young physicians become successful fying and giving gift certificates to RNs whose surgeons and broaden their skills and take patients return their satisfaction surveys at their these skills to other first postoperative counties. Watching visit). Quality assurthe surgeons build ance for my facility In struggling to manage several positions, involves the use of the please physicians and patients, and maintain a their practices, seeing their families grow, Accreditation Associa- happy and well-adjusted staff, I have learned how to be more proactive as a team member knowing how they tion for Ambulatory and cultivate leadership skills. care for their patients, Health Care model. and knowing that the We have a quality staff members and I management commitare part of their practicedall of this has made tee composed of the three physicians, an anesthesia me proud to be in health care. My team and I representative, a scrub technician, one of my medare proud of our ASC’s ability to provide care ical records staff, and me. There is a governing and to turnover rooms quickly; and our patient body to which members of the quality managesatisfaction surveys support our success. ment committee report, and, as the licensed risk manager for my facility, I complete quarterly incident reports, provide the information to the comTHE CHANGING FACE OF AMBULATORY mittee without identifying the persons involved, CARE and discuss how we can prevent future incidents According to the executive director of the Texas and improve patient care. I use a tool to track Ambulatory Surgery Center Society, in 2013, there negative outcomes for patients (eg, pulmonary were 5,260 ASCs in the United States1; at the same embolisms), and we develop interventions to time, the American Hospital Association stated that reduce this outcome. I report this information there were 5,724 hospitals in the United States.2 to both the quality management committee and Ambulatory surgery centers in Texas may soon the ASC’s governing body. As the licensed risk outnumber hospitals, and, in some states, they manager, I must file an annual report with the already do.1 According to the Ambulatory Surgery state, and I am often the driver behind the Center Association, 65% of ASCs are physician everyday question, “What can we do better?” owned, and these facilities offer patients a model of As a result of working in an ASC, I have learned care that “allows patients to deal directly with their to handle all kinds of situations and have called health care provider in a more patient-centered on strengths that I did not realize I possessed. It and personalized setting.”1 Strong physician inhas been an amazing, sometimes frustrating, and volvement is known to promote “direct knowledge always educational eight years. During this time, I of patient care, reduction in frustrating wait times have acquired a different opinion of perioperative for patients and better patient-doctor interaction.”3 532 j AORN Journal
AMBULATORY BEST PRACTICES With changes in health care funding and advances in technology, development of new ASCs will continue because of the cost advantages they provide. As a result, more perioperative personnel will be needed in the ASC setting. These personnel must be flexible, well-rounded clinicians. Staff members must be able to float from area to area. A staff person may work the preoperative area at the start of the day, provide circulator lunch relief, and then provide care in the postanesthesia care unit in the afternoon. He or she also may need to scrub. In addition, personnel must be willing to clean patient care equipment and wipe down patient monitoring equipment. Being well rounded entails ASC personnel being able to interact positively on a daily basis with the public. As a nurse in a main OR setting, I rarely came in contact with family members. In an ASC, however, personnel may be admitting or discharging patients and are responsible for updating family members in person during a procedure, providing postoperative instructions, and performing any number of other tasks that require contact with patients’ family members. Most perioperative health care providers are focused on discovering the right mix of patients and procedures that can be performed safely outside of the traditional hospital OR. Ambulatory surgery centers are uniquely poised to direct how quality surgical patient care is provided in the years to come. CONCLUSION I have networked with leaders from other ASCs and listened to the unique approaches that they have devised to resolve issues and improve their patient care. I want to be able to share in that information and see it showcased to professionals in similar situations. Managers rely on networking, using the Internet, and marshaling resources to solve whatever problems arise. Some of the information found can be misleading or incorrect,
www.aornjournal.org
so managers have to learn from whom and where to solicit help. This is one of the reasons it is so valuable that AORN is becoming more of a presence in the ASC arena. AORN has the resources and the respect of nurses, physicians, industry manufacturers, and vendors to build a strong program for ASCs of all types. The potential is there to provide services that are not cost prohibitive and provide standards for quality care. AORN partnering with already existing ambulatory surgery organizations is a win/win situation. When it comes to finding solutions for perioperative needs, I want to open my AORN Journal and read about the issues I face every day and how other perioperative RNs have resolved them. I am excited that the Journal wants to be the leader in showcasing ASC perioperative nursing. I know there are talented and hard-working ASC leaders, managers, and nurses who just need a little push to get them to share what they are doing and how they are surviving in health care today. What better place to share this information than in the Journal? References 1. ASCs: a positive trend in health care. Ambulatory Surgery Center Association. http://www.ascassociation.org/ AdvancingSurgicalCare/aboutascs/industryoverview/ apositivetrendinhealthcare. Accessed August 21, 2014. 2. Facts on US hospitals. American Hospital Association. http://www.aha.org/research/rc/stat-studies/fast-facts .shtml. Accessed August 13, 2014. 3. Ambulatory surgery centers may soon outnumber hospitals [The Daily Briefing]. The Advisory Board Company. http://www.advisory.com/Daily-Briefing/2013/ 01/31/Ambulatory-surgery-centers-may-soon-outnumber -hospitals. Accessed August 21, 2014.
Sarah Logue, BSN, RN, CNOR, LHCRM, is director of nursing at Paddock Park Surgery Center, Ocala, FL. Ms Logue has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
AORN Journal j 533
I
f you had asked me 10 years ago whether perioperative ambulatory nursing would be my career path, I would have laughed. I was a hardworking hospital perioperative nurse who circulated, scrubbed, and took call frequently, and I could not imagine how outpatient surgeries could compare with what I viewed as the life-changing and often life-saving procedures we performed every day in the hospital setting. At that time, I viewed outpatient surgeries as being mostly simple procedures, such as tonsillectomies and cataracts. My perception then was that “real” OR nursing took place only in the hospital setting. Although the demand for ambulatory services continues to increase in the United States, perioperative nurses may have incorrect perceptions about ambulatory care nursing. What follows is my experience in overcoming my perceptions about ambulatory care. The purpose of sharing my story is to help other perioperative nurses expand their outlook on ambulatory surgery center (ASCs) and the role of nurses in the outpatient setting. BACKGROUND After my husband underwent open heart surgery, our lives changed forever, and there were new personal matters to balance with professional obligations. Part of that change required us to move
from one area of the country to another. I began a new OR position in a hospital that had recruited me. This new hospital setting, however, did not fulfill my understanding and expectations of the job. In particular, I did not have the support that I had known in my previous nursing positions. Instead of being valued for my previous clinical experience, I had to start over and prove myself to a new set of physicians, anesthesia professionals, and fellow OR personnel. In addition, the interpersonal culture of the hospital OR was not ideal (eg, lack of support for a team concept in the OR, lack of valuing each team member as equally important). I felt pressured to circulate and scrub procedures that my colleagues did not want as well as to take more on-call shifts than others did. During the course of this experience I questioned what I believed about being a perioperative nurse. I realized that I needed to change not only my outlook on nursing but also my professional situation. NEW BEGINNINGS, NEW PERCEPTIONS While I was searching for a solution to my job situation, two surgeons who owned an ambulatory plastic surgery facility offered me the opportunity to broaden my OR skills in a unique waydby managing their ASC. These surgeons were in the process of bringing on two more board-certified
The AORN Journal is seeking contributors for the Ambulatory Best Practices column. Interested authors can contact the column coordinator, Debra Garton, by sending topic ideas to [email protected]. http://dx.doi.org/10.1016/j.aorn.2014.08.005
530 j AORN Journal
November 2014 Vol 100
No 5
Ó AORN, Inc, 2014
AMBULATORY BEST PRACTICES
www.aornjournal.org
imply that corporate-owned ASCs do not expeplastic surgeons, to allow them to meet their goals rience some of the same operational challenges of increasing the size of the center’s patient base and issues that small, single-specialty, physicianwhile remaining a single-specialty, physicianowned facilities encounter; however, transitionowned facility. I accepted the position because ing from the hospital setting to an ambulatory the surgeons convinced me that they valued the setting in which there are no other departments, entire team and that teamwork was how they resources, or mentors to help resolve an issue wanted to care for patients. was an eye-opening experience for me. Very quickly my new role began to challenge Another misperception of the ambulatory setting my perceptions of what it means to be an ASC is that there is little structure compared with the nurse. Instead of having a primary nursing focus, main OR setting. However, the opposite is true, as manager of an ASC, I assumed several roles, in particular with staffing plans and on-call strucsome that I had never performed before in the tures. My staff members and I are not required clinical setting. In addition to being the RN circuto work long days and then mandatory on-call lator for procedures, at other times, I was the preshifts. It is a rare thing for staff members to work operative or postoperative nurse. I scheduled a weekend shift, and personnel in the ASC I have developed a and in the physicians’ Transitioning from the hospital setting to an call tree for instances clinical practices. I ambulatory setting in which there are no other when a physician was a safety officer, departments, resources, or mentors to help needs to come into a quality assurance/ resolve an issue was an eye-opening experithe clinic on a weekprocess improvement ence for me. end. I have instituted specialist, licensed several flexible schedrisk manager, and an ules to accommodate infection prevention different staff member needs in the ASC and the nurse. I created policies and procedures, and was two clinical offices. I work diligently to cover all the go-to person for anything these documents of the responsibilities for various areas because I did not address. In addition, I came into the appreciate that the physicians never complain physicians’ clinics on weekends and after hours when I am out of the office. There have been when they needed to see patients. some weeks that I have worked 48 to 50 hours, This ASC was not part of a large management but these hours do not compare with the somecompany or owned by physicians in multiple spetimes 60 to 70 hours that I often worked in the cialties. Generally, small physician-owned ASCs hospital setting. have more financial and operational challenges Culturally, the ASC promotes teamwork and in terms of providing patient care and remaining supportive interpersonal dynamics. The physisolvent, unless the center performs eye, orthopedic, cians respected me from the outset, and I conor endoscopic surgery (ie, these procedures have tinue to feel valued for my input. Staff members a higher volume and easier turnover, which transreceive generous benefits that do not automatilates to higher revenue per OR minute). Comcally expire if unused. There are bonuses, and paratively, larger centers attached to corporations the benefit of working in a plastics facility with or hospitals have greater resources. For example, a medical spa. The facility has very little staff when setting up a new service or when working turnover, and I work with a terrific team. In on a necessary policy change, staff members at addition, working at an ASC has helped stabithese facilities have consultants or mentors who lize my work/life balance. can guide them through the process. This is not to AORN Journal j 531
November 2014 Vol 100
No 5
AMBULATORY BEST PRACTICES
peers who work in free-standing ASCs. In strugPROFESSIONAL GROWTH gling to manage several positions, please physiDeveloping a new outlook about what it means to cians and patients, and maintain a happy and be an ambulatory perioperative nurse has allowed well-adjusted staff, I have learned how to be me to grow professionally. I have learned so much more proactive as a team member and cultivate by working in an ASC. I have performed quality leadership skills that I never would have had the improvement studies by using unique approaches opportunity to develop in my previous nursing to address an issue (eg, being solely responsible positions. for determining a need and for devising and imIn my ASC, I also had the privilege of watchplementing a strategy to meet that need; identiing two young physicians become successful fying and giving gift certificates to RNs whose surgeons and broaden their skills and take patients return their satisfaction surveys at their these skills to other first postoperative counties. Watching visit). Quality assurthe surgeons build ance for my facility In struggling to manage several positions, involves the use of the please physicians and patients, and maintain a their practices, seeing their families grow, Accreditation Associa- happy and well-adjusted staff, I have learned how to be more proactive as a team member knowing how they tion for Ambulatory and cultivate leadership skills. care for their patients, Health Care model. and knowing that the We have a quality staff members and I management commitare part of their practicedall of this has made tee composed of the three physicians, an anesthesia me proud to be in health care. My team and I representative, a scrub technician, one of my medare proud of our ASC’s ability to provide care ical records staff, and me. There is a governing and to turnover rooms quickly; and our patient body to which members of the quality managesatisfaction surveys support our success. ment committee report, and, as the licensed risk manager for my facility, I complete quarterly incident reports, provide the information to the comTHE CHANGING FACE OF AMBULATORY mittee without identifying the persons involved, CARE and discuss how we can prevent future incidents According to the executive director of the Texas and improve patient care. I use a tool to track Ambulatory Surgery Center Society, in 2013, there negative outcomes for patients (eg, pulmonary were 5,260 ASCs in the United States1; at the same embolisms), and we develop interventions to time, the American Hospital Association stated that reduce this outcome. I report this information there were 5,724 hospitals in the United States.2 to both the quality management committee and Ambulatory surgery centers in Texas may soon the ASC’s governing body. As the licensed risk outnumber hospitals, and, in some states, they manager, I must file an annual report with the already do.1 According to the Ambulatory Surgery state, and I am often the driver behind the Center Association, 65% of ASCs are physician everyday question, “What can we do better?” owned, and these facilities offer patients a model of As a result of working in an ASC, I have learned care that “allows patients to deal directly with their to handle all kinds of situations and have called health care provider in a more patient-centered on strengths that I did not realize I possessed. It and personalized setting.”1 Strong physician inhas been an amazing, sometimes frustrating, and volvement is known to promote “direct knowledge always educational eight years. During this time, I of patient care, reduction in frustrating wait times have acquired a different opinion of perioperative for patients and better patient-doctor interaction.”3 532 j AORN Journal
AMBULATORY BEST PRACTICES With changes in health care funding and advances in technology, development of new ASCs will continue because of the cost advantages they provide. As a result, more perioperative personnel will be needed in the ASC setting. These personnel must be flexible, well-rounded clinicians. Staff members must be able to float from area to area. A staff person may work the preoperative area at the start of the day, provide circulator lunch relief, and then provide care in the postanesthesia care unit in the afternoon. He or she also may need to scrub. In addition, personnel must be willing to clean patient care equipment and wipe down patient monitoring equipment. Being well rounded entails ASC personnel being able to interact positively on a daily basis with the public. As a nurse in a main OR setting, I rarely came in contact with family members. In an ASC, however, personnel may be admitting or discharging patients and are responsible for updating family members in person during a procedure, providing postoperative instructions, and performing any number of other tasks that require contact with patients’ family members. Most perioperative health care providers are focused on discovering the right mix of patients and procedures that can be performed safely outside of the traditional hospital OR. Ambulatory surgery centers are uniquely poised to direct how quality surgical patient care is provided in the years to come. CONCLUSION I have networked with leaders from other ASCs and listened to the unique approaches that they have devised to resolve issues and improve their patient care. I want to be able to share in that information and see it showcased to professionals in similar situations. Managers rely on networking, using the Internet, and marshaling resources to solve whatever problems arise. Some of the information found can be misleading or incorrect,
www.aornjournal.org
so managers have to learn from whom and where to solicit help. This is one of the reasons it is so valuable that AORN is becoming more of a presence in the ASC arena. AORN has the resources and the respect of nurses, physicians, industry manufacturers, and vendors to build a strong program for ASCs of all types. The potential is there to provide services that are not cost prohibitive and provide standards for quality care. AORN partnering with already existing ambulatory surgery organizations is a win/win situation. When it comes to finding solutions for perioperative needs, I want to open my AORN Journal and read about the issues I face every day and how other perioperative RNs have resolved them. I am excited that the Journal wants to be the leader in showcasing ASC perioperative nursing. I know there are talented and hard-working ASC leaders, managers, and nurses who just need a little push to get them to share what they are doing and how they are surviving in health care today. What better place to share this information than in the Journal? References 1. ASCs: a positive trend in health care. Ambulatory Surgery Center Association. http://www.ascassociation.org/ AdvancingSurgicalCare/aboutascs/industryoverview/ apositivetrendinhealthcare. Accessed August 21, 2014. 2. Facts on US hospitals. American Hospital Association. http://www.aha.org/research/rc/stat-studies/fast-facts .shtml. Accessed August 13, 2014. 3. Ambulatory surgery centers may soon outnumber hospitals [The Daily Briefing]. The Advisory Board Company. http://www.advisory.com/Daily-Briefing/2013/ 01/31/Ambulatory-surgery-centers-may-soon-outnumber -hospitals. Accessed August 21, 2014.
Sarah Logue, BSN, RN, CNOR, LHCRM, is director of nursing at Paddock Park Surgery Center, Ocala, FL. Ms Logue has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
AORN Journal j 533
