Exploring the Role of the Nurse in Ambulatory Care Environments: A Qualitative Study

Ambulatory healthcare is rapidly changing, driven by an increase in consumer demand, advances in technology, changing patient demographics, and improved reimbursement (American Academy of Ambulatory Care Nursing [AAACN], 2017; Nundy et al., 2022). Advances in technology and experiences with the COVID-19 pandemic have led to innovations in healthcare delivery, such as telehealth and virtual appointments. Despite trends and innovations, we found little research that explored the role of the nurse in ambulatory care, rather than descriptions of tasks and daily activities they might perform.

Background

Much of the literature on the nurse in ambulatory care has been anecdotal or published in editorials and positions statements. Within the literature, terms such as titles, responsibilities, tasks and daily activities are used interchangeably, yet each has a distinct meaning that is different from the definition of role. For this reason, finding research about the role of the nurse in ambulatory care is difficult. In a search of the research literature about nurses in ambulatory care settings from 2014 to 2022, we found only one study reported in English (Rondinelli et al., 2014). However, Rondinelli et al. did not explore the role of the nurse, rather they reported activities nurses engaged in most often in the ambulatory care setting. Because we found no studies that explored the role of the nurse in ambulatory care, versus the tasks and activities performed by the nurse, the purpose of our study was to address this gap.

Methods

Design
This qualitative descriptive study used an interview format with semi-structured questions to explore how nurses described their roles in the ambulatory care environment. For this study we adhered to the consolidated criteria for reporting qualitative research (COREQ) criteria (Tong et al., 2007).

Population and Setting
Registered nurses with at least one year of experience in an ambulatory care setting were invited to participate. Excluded were nurses in management positions, care coordination, advanced practice roles, as well as nurses who worked in the emergency department, ambulatory surgery, or in telehealth settings. The study took place at a quaternary academic medical center in the Midwest United States.

Recruitment
Nurses were notified about the study and invited to participate through email invitations. Those interested in participating were scheduled for an interview with the principal investigator at a time and place of their choosing. Using purposive sampling, we made an intentional attempt to recruit a diverse sample related to race, gender, and geographic location. (AUTHORS: I think readers would benefit from a little more information about what type of diversity you were seeking. I added a few thoughts in here to represent common areas of diversity. Please review this and correct accordingly to match your goals. Thanks, Jackie) Recruitment of participants ended when data saturation was achieved. Data saturation was defined as obtaining no new content for three consecutive interviews (Saunders et al., 2017).

Protection of Human Subjects
The study was approved by the medical center institutional review board. Verbal informed consent was obtained prior to the interview. Demographic and interview data were collected without identifiers and stored in a password protected folder, on an encrypted computer.

Data Collection
A single semi-structured interview was conducted in-person or by telephone in a private setting. Participants (n=19) were asked for demographic information (e.g., age, experience, sex, employment status, specialty) followed by three open ended questions (see Table 1). Interviews were audio-recorded and contemporaneous notes were documented. Interviews lasted between 20 and 45 minutes.

Table 1. Interview Questions

Data Analysis
Thematic analysis techniques were used to explore the data. Thematic analysis is an iterative process in which patterns are identified (Braun & Clarke, 2019). The analysis process consists of several stages: becoming familiar with the data, coding, generating themes, reviewing themes, and then refining themes (Braun & Clarke, 2019).

Trustworthiness
Lincoln and Guba’s (1985) criteria for trustworthiness were used to ensure rigor in designing the study and completing the analysis. For example, interviews were conducted by a single interviewer (MMB) to maintain a consistent approach and the entire research team reviewed audio-recordings together, using an iterative process. Direct quotes from the participants were used to support the emerging themes.

Findings

Characteristics of Participants
Nineteen nurses participated in interviews. Nurses were primarily female, worked full-time, held a bachelor’s degree, and had over 10 years of ambulatory care experience (see Table 2).

Table 2. Characteristics of Registered Nurse Sample

NOTE: SD = standard deviation; n = frequency, % = percent

Some nurses entered ambulatory care intentionally because they were seeking a change from the acute care environment; others chose to work in ambulatory settings for personal reasons (e.g., family responsibilities). Sixty-eight percent (n=13) of the nurses interviewed identified the need for work-life balance as their initial reason for seeking a position in ambulatory nursing. While many nurses intentionally sought positions in ambulatory settings, a few unintentionally ended up in ambulatory roles because a good opportunity presented. Once practicing in the ambulatory setting, many identified that it provided a satisfying work-life balance. Longevity of service resulted from the nurses engaging in enjoyable patient contact, opportunities for effective teaching, and the belief that they were respected by patients, providers, and staff in the ambulatory setting.

Emerging Themes: Nursing Roles in Ambulatory Care
Nurse participants had a difficult time describing their roles in the ambulatory care setting. Many described roles in terms of tasks and daily activities. Defining nursing and nursing practice in terms of roles, versus tasks and daily activities, has always been a challenge, as nurses in different situations will perform different tasks (e.g., medication administration, rooming, answering the phone, documentation, scheduling) and use different skills (e.g., assessment, triage, monitoring). Identifying the similarities that transcended the location or specialty within the ambulatory setting was needed to clarify the role of the nurse. Based on analysis of our data, three themes related to roles of the nurse emerged: patient advocate, teacher, and departmental anchor.

(AUTHORS: I revised your subheadings here to match the terms that you used in the keywords. I think that will improve searchability and help readers to make the connection. I am always a fan of using consistency in terms. However, I’m not married to this – if you wanted the way you have it, we can change it back. Jackie)

Nurse as Advocate. The role of nurses as a patient advocate is critical to assure a high reliability environment. High reliability organizations aim to prevent harm and promote safety through advocacy (Sculli et al., 2022). The nurses we interviewed spoke of intervening as needed to ensure that patients obtained appointments, tests, medications, and to assure that they received high quality care.

Nurses feel a responsibility to patients and their families, and this leads them to think beyond these types of tasks and to operationalize their role as advocates. One nurse shared a story about provider orders that did not seem appropriate at the time as the patient’s condition had changed since the original order was written. The nurse communicated to the provider that there had been a change in the patient’s condition and new orders were warranted. However, the nurse was not initially successful in obtaining new orders; he eventually had to seek out another provider to address the issue. New, more appropriate orders were received because of this nurse’s advocacy.

Nurse as Teacher. When asked to describe their typical day in ambulatory care, nurses often discussed their patients’ educational needs such as understanding their diagnoses, medication side effects, and the importance of follow-up care. The nurse’s role as teacher is complex and involves not only providing individualized knowledge for a particular patient, but also developing effective nurse-patient relationships.

One nurse commented, “I always try to re-explain [to the patient] what was presented [by the provider]. I find that the information provided to patients is ‘sketchy’… Maybe the patient did not hear it clearly the first time.”

Effective nurse-patient relationships are both time and situationally important. Another nurse explained how “knowing the patient” allowed her to make decisions about how and when to bring up various educational topics. The nurse stated:

You are meeting them [the patient] where they are at… building a relationship over time…. you know if their mom just died a month ago, that’s going to affect their health and decision-making, and whether they are ready to talk about quitting smoking…

Nurse as Anchor. Departmental anchor is perhaps the most important and the most under-rated of all roles demonstrated by the nurse in ambulatory care. This is seldom formal, but rather plays out as an informal role whereby the nurse provides oversight and support for everyone (i.e., patients, families, staff, and providers) and everything. One nurse explained that compared to an in-patient setting where “there is always somebody available to consult when a question arises, in the ambulatory setting, the nurse is the one that is being consulted.” Nurses are expected to know what to do when things do not go well (e.g., medical emergencies, staff call-offs, missing or malfunctioning equipment). Thus, the nurse makes sure the clinic runs smoothly, thereby optimizing the patient’s experience and the provider’s time.

Nurses operationalized the departmental anchor role in several ways. One nurse shared a story about a provider who wanted a patient to follow up in a certain amount of time, but the provider’s schedule had no availability for an appointment. It fell to the nurse to determine how to schedule the patient, considering both the patient’s condition and the provider’s schedule.

Another nurse described a situation where a patient who had an order for a single knee x-ray, but complained of pain in both knees. It was the nurse who stopped the x-ray procedure and had the order clarified to include both knees. This nurse’s action saved patient and provider time, and resources.

Finally, one nurse shared that if equipment in the clinic breaks it is the nurse who is notified and determines how to proceed with the rest of the day. Malfunctioning equipment disrupts the provider’s schedule and patient care. Again, it is the nurse who rearranges the schedule and handles the equipment repair.

Impact of Clinical Environment on Roles
A fourth theme emerged related to the impact of the clinical environment on the nursing roles. The roles of nurses in ambulatory care settings are expressed differently and to different degrees, depending upon environmental differences. Staffing patterns often vary significantly and specialties each require the nurse to perform different tasks. Some clinics are large, and some are small. Larger clinics had more people and resources than smaller clinics. However, as appointment numbers reflect the number of providers, and not the size of the clinic, the nurses typically expressed concerns about the demands on their time. These demands most commonly impacted the performance of the advocate and teacher roles as the departmental anchor role tends to take precedence regardless of environment. For example, one nurse said that she was,

Being pulled in multiple directions so you can’t take your time…makes you abbreviate stuff you don’t want to abbreviate. We get behind and I have to rush through the teaching thing that I would rather take a little bit more time on.

Discussion

This study described the various roles from the perspective of nurses in ambulatory care in a wide range of settings (e.g., large and small, primary and specialty). Unlike Anderson et al. (2012) and Rondinelli et al. (2014), we conceptualized the role of the nurse in ambulatory care as more than and different from a list of tasks or activities. While tasks and daily activities may vary, nursing roles, no matter the environment, remain constant. Nurses are advocates, teachers, and the anchor upon which the unit or department depends to function smoothly. The ability to perform these roles may enhance patient satisfaction and promote better patient outcomes; the opportunity may also enhance nurse satisfaction and contribute to retention of nurses in this setting. Understanding the roles that nurses in ambulatory care settings fulfill daily is important to better understanding the value that these nurses add to these settings.

Strengths
Data for this study were recorded and specific conversations were transcribed verbatim. This required multiple sessions of listening to recordings by the research team to extract not only comments but the tone of responses. Previous researchers have noted that meaning and content are often lost when the voice of the participant is removed through transcription alone (Parameswaran et al., 2020; Tessier, 2012). Thus, we tried to preserve both the words and the tone found in the interviews through repeated audio review of our session recordings. Finally, as no previous studies were found that explored the role of the nurse in this manner (i.e., roles instead of tasks), this study addressed the specific gap in the literature, and helped to clarify the difference between nursing roles and nursing activities and/or tasks.

Limitations
A sample drawn from a single healthcare system setting is the major limitation of this study. However, we made numerous attempts to recruit participants from different ambulatory settings, and to include male and female nurses, as well as new and experienced nurses. In addition, the single healthcare system we used is extremely large, with 61 family health centers and primary care sites and several hundred clinics. Findings from qualitative research seek a rich description rather than generalizability to other settings. Other geographic locations and clinic settings may present very different environments, and this may impact the roles that a nurse in ambulatory care assumes in those settings. However, it is appropriate to judiciously consider how the nursing roles described in our emerging themes could be a feature of nurses and other ambulatory care settings.

(AUTHORS: As a qualitative researcher, I try for words both acknowledge the limitations of qualitative methodology but also present the benefit of seeking rich descriptions appropriate to this type of research. To that end, I have done some editing of your limitations to help readers appreciate the transparency of them, but also consider the benefit of your work using this methodology. I shudder a little bit when it feels like qualitative research is less than, rather than different than. :) Because it is not statistically generalizable does not mean that one can’t think about applicability in other settings, and does not make it less valuable. That is the point I am trying to make. However, I am always open to discussion about my edits, so if you feel that I have overstated my thoughts above, I’m sure we can reach consensus on language that will work for all of us. Feel free to let me know! Jackie)

Recommendations for Further Research
This is one of the first known studies to explore the roles, rather than tasks or daily activities, of nurses in ambulatory care settings. As such, it is important that other researchers consider replicating this study in different organizations and countries to build on our findings. Finally, the impact each role has on both nurse and patient outcomes requires further research to determine the value added when nurses in ambulatory care settings fulfill each of the roles identified in this study.

Implications for Policy and Practice
In addition to the three roles that emerged in this study, it was apparent that the nurses we interviewed perceived several benefits and challenges related to their choice of ambulatory nursing as a specialty. Benefits included work-life balance and more time to build relationships with patients, families, and providers. These benefits may account for the longevity and job satisfaction deemed important to nurses (American Nurses Foundation, 2023).

Although nurses in our study articulated the benefits of ambulatory nursing, they also shared some of the challenges. Many of these challenges were impacted by the environment in which the nurses practiced. Some nurses felt rushed when delivering patient care, others complained of limited access to ancillary resources in the environment. These challenges might impact the ability of nurses in ambulatory care to fulfill the three roles that emerged from our data. Thus, to grow and sustain the ambulatory care workforce, policy makers and leaders need to pay attention to the needs of nurses. A nurse needs to be viewed as a professional with important roles that make a difference in patient satisfaction and outcomes, rather than just someone who completes a list of tasks or daily activities.

Conclusion

In conclusion, this qualitative descriptive study used an interview format with semi-structured questions to explore how nurses described their role(s) in the ambulatory care environment. Analysis of the interviews revealed that nurses in the ambulatory settings identified their roles as patient advocates, teachers, and as departmental anchors. The specific environment in which a nurse practices influences how each role will be implemented. It is the implementation of these critical nursing roles that may have the most impact on patient satisfaction and patient outcomes.

Acknowledgements
We would like to acknowledge Christian Burchill, PhD, MSN, RN, CEN for his support and help beginning this project. We have no conflicts of interest to disclose.

Authors

Michelle M. Braunscheidel, BSN, RN
Email: braunsm@ccf.org
ORCID ID: 0009-0008-2237-4317

Michelle M. Braunscheidel is an Ambulatory Nurse, Department of Ambulatory Nursing, Cleveland Clinic, Cleveland, OH. Correspondence concerning this article should be addressed to her at Michelle M Braunscheidel, Department of Ambulatory Nursing, Cleveland Clinic, Cleveland, OH using the email above or mbbraunscheidel@gmail.com. Mailing address is 37967 French Creek Rd. Avon, OH 44011.

Rita Lovelace, BSN, RN, CCCTM
Email: RLovelace@ccf.org

Rita R. Lovelace is Primary Care Coordinator Ambulatory Care Management Cleveland Clinic, Independence, OH.

Brian Rink, MSN, MBA, RN, NEA-BC
Email: rinkb@ccf.org

Brian Rink is Senior Director Care Management Southern Region, Zielony Institute for Nursing Excellence, Cleveland Clinic, Cleveland, OH.

Lorraine M. Novosel, PhD, RN, APRN-CNP, AGPCNP-BC
Email: novosel@ccf.org
ORCID ID: 0000-0001-6195-7170

Lorraine M. Novosel is Nurse Scientist I, Office of Nursing Research and Innovation, Zielony Institute for Nursing Excellence, and Consultant Staff, Lerner Research Institute, Cleveland Clinic, Cleveland, OH.

Cynthia A. Danford, PhD, CRNP, PPCNP-BC, CPNP-PC, FAAN
Email: danforc@ccf.org
ORCID ID: 0000-0003-2391-0632

Cynthia A. Danford is Nurse Scientist II, Office of Nursing Research and Innovation, Zielony Institute for Nursing Excellence, and Consultant Staff, Lerner Research Institute, Cleveland Clinic, Cleveland, OH.

Sandra L. Siedlecki, PhD, RN, APRN-CNS, FAAN
Email: siedles@ccf.org
ORCID ID: 0000-0001-9886-0663

Sandra L. Siedlecki is Senior Nurse Scientist, Nursing Research & Innovation, Consultant Staff-Lerner Research Institute, Cleveland Clinic, Adjunct Assistant Professor, Frances Payne Bolton School of Nursing at CWRU, Cleveland, OH.