T

Nursing retention is directlyrelated to the workplace. Best-practice literature confirmsthat health care workplaceculture has an impact on boththe quality of services thathealth care professionals pro-vide, as well as the level ofsatisfaction and commitmentto the workplace from thosesame professionals. This arti-cle will review how one facilityin Alberta, Canada, imple-mented changes in their nurs-ing leadership to effectivelyincrease staff retention.

“There is a hole in thebucket, dear Liza, dear Liza,there’s a hole in the bucket,dear Liza, a hole.” Thesewords from a traditional chil-dren’s song illustrate a veryreal problem for many nurs-ing work environments today– staff turnover or lack ofnursing retention. Mary-Anne Robinson (2008), exe-cutive director of the Collegeand Association of Regis-tered Nurses of Alberta,states, “When your bucket isleaky, it’s foolish to continu-ally go back to the well to fillit. Rather, it is much morereasonable to do everythingpossible to minimize theleakage.” Though there is no ‘one size fitsall’ retention program, the aim of this articleis to provide an overview of frameworks thatcan be used to examine issues of nursingretention, as well as offer suggestions foraction to produce positive, nurse telehealthwork environments.

It is evident in best-practice literaturethat health care workplace culture has animpact on both the quality of services that

The Official Publication of the American Academy of Ambulatory Care Nursing

Volume 30 Number 4

health care professionals provide, as well asthe level of satisfaction and commitment tothe workplace from these same health careprofessionals. Data show higher levels of clin-ical engagement in places of employmentthat are deemed as respectful, high-qualityworkplaces by those working in them(Domm, Smadu, & Eisler, 2007). Indeed, aworkplace where nurses enjoy going to

continued on page 8

Contact hour instructions, objectives, and accreditation information may be found on page 11.

JULY/AUGUST 2008

Inside

FEATURESPage 3Health Literacy: BetterPractices for BetterOutcomesDiscover how you and your staffcan learn to communicate betterwith patients and their families.

Page 4Evaluating Peripheral IVGuidelines for theOutpatient SettingThis article explores a comparisonof costs of various peripheralintravenous securing practices.

AAACN NEWS

Page 6Congratulations to NewlyCertified AAACN Members!

Page 14Real Nurses, Real Issues,Real Solutions

Page 15Are You Taking FullAdvantage of Your AAACNBenefits?

Page 16AAACN 34th AnnualConventionPlan Now to Attend!

Patricia ChambersLara Mazzei

PLAN NOWt o a t t e n d !

2 V I EWPO I NT J U LY /AUGU ST 2008

From thePRESIDENT

Real Nurses. Real Issues. Real Solutions.

American Academy ofAmbulatory Care Nursing

Reader ServicesAAACN ViewpointThe American Academy of AmbulatoryCare NursingEast Holly Avenue Box 56Pitman, NJ 08071-0056(800) AMB-NURSFax (856) 589-7463E-mail: aaacn@ajj.comWeb site: www.aaacn.org

AAACN Viewpoint is owned and publishedbimonthly by the American Academy ofAmbulatory Care Nursing (AAACN). Thenewsletter is distributed to members as adirect benefit of membership. Postage paid atBellmawr, NJ, and additional mailing offices.

AdvertisingContact Tom Greene, AdvertisingRepresentative, (856) 256-2367.

Back IssuesTo order, call (800) AMB-NURS or(856) 256-2350.

Editorial ContentAAACN encourages the submission of newsitems and photos of interest to AAACN mem-bers. By virtue of your submission, you agreeto the usage and editing of your submissionfor possible publication in AAACN's newslet-ter, Web site, and other promotional and edu-cational materials.

To send comments, questions, or article sug-gestions, or if you would like to write for us,contact Editor Rebecca Linn Pyle atbeckypyle@msn.com

AAACN Publications andProductsTo order, visit our Web site: www.aaacn.org.

ReprintsFor permission to reprint an article, call(800) AMB-NURS or (856) 256-2350.

SubscriptionsWe offer institutional subscriptions only. Thecost per year is $80 U.S., $100 outside U.S.To subscribe, call (800) AMB-NURS or (856)256-2350.

IndexingAAACN Viewpoint is indexed in theCumulative Index to Nursing and AlliedHealth Literature (CINAHL).

© Copyright 2008 by AAACN. All rightsreserved. Reproduction in whole or part, elec-tronic or mechanical without written permissionof the publisher is prohibited. The opinionsexpressed in AAACN Viewpoint are those of thecontributors, authors and/or advertisers, and donot necessarily reflect the views of AAACN,AAACN Viewpoint, or its editorial staff.

Publication Management by Anthony J. Jannetti, Inc.

WAmbulatory Care Nursing – A Remarkable Experience

What makes an association remarkable? For me,AAACN is remarkable because of its members and volun-teer leaders. Belonging to AAACN has made a differencein my life and work. This organization represents thethings I hold as important and special in my practice andmy role as an ambulatory care nurse. I am truly blessed tohave such great colleagues and friends. I hope that eachof you has the opportunity to experience the sense ofcommunity and support AAACN offers.

Several months ago, I spoke with Cyndee Hnatiuk,Executive Director of AAACN, about ideas for my acceptancespeech for the national conference. I told her I did not really have a story to tell.Cyndee looked at me and asked, “When did you know you were an ambulatorycare nurse?”

That question stopped me, and I really had to think – when did I know? Itold her this story. As you may or may not know, I work for the Department ofVeteran Affairs and have for almost 30 years. I consider it a privilege to help ourveterans and their families. It is rewarding and can be heartbreaking at the sametime, knowing what they have been through to serve our country. When I firststarted at the VA, I worked at a small facility in the town where I live. We offeredmany services, and it had a definite sense of community and caring. In 1993, weimplemented a primary care program where our patients would see the samenurse and physician at each visit; the goal was to improve the continuity of care.

In 1995, our facility was notified that we would integrate with the facility inSan Antonio to reduce redundant services and streamline costs. When wemerged, I was the assistant chief nurse for acute care, covering inpatient, ICU,urgent care, primary care, and specialty clinics. I was asked by the nurse execu-tive at the San Antonio facility to implement primary care at that facility. This wasaccomplished over a period of six months. When that project was completed, Iwas given other outpatient services, including specialty clinics, the emergencydepartment, and hemodialysis. About six months later, I was told I would haveresponsibility for the five satellite clinics throughout South Texas.

In 1996, I saw a brochure for the AAACN conference in Atlanta. Since myarea of practice was primarily ambulatory care, I wanted to attend. I was espe-cially interested in the telehealth programs, since I was expected to set up a pro-gram for the region. It was during my time at the conference that I discovered Iwas an ambulatory care nurse. The conference was wonderful! I met colleagueswho had the same interests and concerns about practice and patient care as Idid. I joined the VA SIG and became co-chair. I completed the Willingness toServe form, and to my surprise, I received a call asking if I would like to partici-pate on the Program Planning Committee.

I have met the most wonderful people through this organization, and thereare many to thank, including but not limited to Kathy Krone for being a wonder-ful mentor and the president who took us through the first strategic plan; toCatherine Futch for inviting me to a part of the Program Planning Committeeand helping all of us to think outside the box; to Regina Conway-Phillips whoasked me to be her Program Planning co-chair and for being a wonderful friend

Karen Griffin

continued on page 11

I

W W W . A A A C N . O R G 3

patient education materials should focus on highlighting themost important information first, using simple words (highblood pressure rather than hypertension) and providingample white space for easier reading. Using illustrations thatincorporate drawings or models for demonstration is also rec-ommended.

Another important feature is in speaking plainly, as manypatients are auditory learners. The ‘teach-back’ method is rec-ommended for educational interactions. During teach-back,the health care provider teaches the patient, then asks thepatient to repeat the information by restating it in his or herown words. This process can be repeated as many times as isnecessary to ensure there is understanding by the learner.

Using “Plain Language” in the development of informedconsent and insurance forms is also key to enhanced compre-hension. A project completed at the Iowa Health System(2003) recreated consent forms from the collegiate level to the6th and 7th-grade reading level using the “Ask Me 3” format,which asks three basic questions:

• Question 1 – What is my main problem?• Question 2 – What do I need to do?• Question 3 – Why is it important for me to do this?

The IHS Health Literacy Collaborative is an organizationthat was developed in 2003 to improve the quality of care toall patients and their families by revising educational programsand literature related to health literacy (Iowa HealthcareCollaborative, 2003).

“Plain Language” is being used in governmental agencies,private sectors, and around the world. International efforts areunderway to add elements to “Plain Language” documentsthat reflect cultural differences. An example of how “PlainLanguage” could be used in daily practice is to have the healthcare provider carry along a medication bottle to eachencounter and ask the patient to read the instructions backwith an explanation of how he or she would take the medica-tion. Another example would be to provide patients with aprinted copy of the medication reconciliation record after eachencounter or to use a wallet-sized card for patients to keeptrack of their medications at home. With the plethora of med-ications now available, both generic and brand names shouldbe listed to avoid inadvertently doubling the dose of a singlemedication.

On the reimbursement front, many insurance companiesare evaluating reimbursement for trained interpreters forpatients, as well as the provision of premium discounts tohealth care providers that have attended classes on health lit-

continued on page 12

Kathleen Sklenar

In an all too common scenario, a Spanish-speaking patientwas diagnosed with type 2 diabetes mellitus during a recenthospitalization. He was discharged with a prescription forinsulin glargine (Lantus®) and insulin aspart (Novolog®) on asliding scale. Follow up in the ambulatory clinic with his pri-mary care provider revealed no improvement in his blood sug-ars. It was discovered that the patient had been mixing bothinsulins together for one daily dose. The patient was unawarethat Lantus should not be mixed with Novolog because theLantus vial instructions were written in English. How canambulatory care nurses help patients understand healthinstructions? Several promising initiatives to improve health lit-eracy and subsequently to improve patient outcomes are cur-rently underway. This article will identify key examples of theseinitiatives.

The Joint Commission (2007) has begun work on a far-reaching initiative called, “What Did the Doctor Say?Improving Health Literacy to Protect Patient Safety.” As part ofthis initiative, The Joint Commission will be gathering informa-tion on outcomes achieved in patient-centered environmentsthat stress the use of clear communication in all interactions.For example, standardized forms are recommended forpatients who are transferred to different areas in the healthcare organization, in both inpatient and ambulatory careencounters. This approach facilitates a consistent methodolo-gy and clear communication throughout the continuum.

Staff members should be informed about issues surround-ing health literacy and find appropriate teaching materials tomeet patients’ individualized needs. The Speak Up Program(The Joint Commission, 2002) has been an effective tool thatfosters the empowerment of patients. It promotes the patient’sright to ask questions and obtain clarification in order to makeinformed decisions and ultimately improve health care out-comes. Another model program has been introduced to med-ical students at the University of Virginia, emphasizing theimportance of health literacy when communicating withpatients. This program includes not only information on howto set up a program but also a faculty development outline,with the plan to add individualized patient care scenarios in thecoming months (University of Virginia Health Care System,2008).

The United States Department of Health and HumanServices (2008) has developed a visionary program entitled,“Plain Language: Communicating Health Information andImproving Health Literacy,” which encourages a triad ofapproaches. Encouraging the concept of writing plainly, written

4 V I EWPO I NT J U LY /AUGU ST 2008

APamela B. DeGuzmanCynthia McCaskill

A descriptive study was initiated todetermine the cost associated withchanging the existing practice of dress-ing peripheral intravenous catheters(PIVs) with tape and gauze to one usinga transparent, semi-permeable mem-brane dressing, such as Versaderm™ inthe outpatient setting. The change wasadopted for use in all patient care areas,including inpatient, procedures, andoutpatient. Ambulatory care nursesbelieved that the change would not becost-effective or necessary in their prac-tice setting. The study demonstratedthat over 1,000 short dwell-time PIVswere inserted over a 4-week period in 6outpatient settings. Based on these num-bers, using the Versaderm™ method wasprojected to cost more than $8,000annually. Would PIV securing practices inthe outpatient setting require adoptionof the more expensive Versaderm™method?

BackgroundIn August 2006, a practice change

for the adherence and securement of PIVcatheters (such as Versaderm) was imple-mented in all patient care areas at theinstitution. Previous research by nurses atthe hospital supported the change toVersaderm™ for the purpose of stabiliza-tion and adherence (Winfield et al.,2007). The previous practice throughoutthe institution had been to use gauze andtape for PIV dressings, which did notoptimize site visualization.

Despite the evidence-based re-search that supported the change toVersaderm, there were multiple objec-tions voiced in the outpatient setting tothe new practice. Some areas contin-ued to use sterile gauze and tape tosecure PIVs. The cost increase ofVersaderm was thought to be signifi-cant and unnecessary since the dwell

times of PIVs in these areas were usual-ly quite short. A study was designed todetermine dwell times of PIVs placed inoutpatient clinics and to estimate thecost of changing existing practice tothe one using Versaderm.

Reviewing the EvidenceDuring the review of evidence, it

was discovered that very short-termPIVs are not addressed in the literature.The Centers for Disease Control andPrevention (CDC) has published guide-lines for PIV therapy (Nicoll & Ambler,2005) that summarize much of the lit-erature. However, no discussion wasfound on IVs that were intended to bein place for less than 12 hours. In somecases, the literature defined short-termIVs in terms of days, not hours.According to Royer (2003), the averagedwell time for a PIV is 2.45 days.

Table 1.Cost Difference Across Outpatient

1,018 N= Number of infusions over 4 week period*

12.5 M = 4 week periods per year

12,725 TI = Total Infusions per year (N x M)

$ 0.02 GT= Cost of Gauze and Tape per patient

$ 254.00 GTA = Annualized cost of Gauze and Tape (GT x TI)

$ 0.64 V = Cost of Versaderm per patient

$ 8,144.00 VA = Annualized Cost of Versaderm (V x TI)

$ 7,890.00 Annualized Cost Difference between Gauze and Tape vs. Versaderm

Table 2.Basic Statistics for Dwell Time in

All Ambulatory Units

N 1,018Mean (minutes) 186.0Standard Deviation(minutes) 118.8

Table 3.Basic Statistics for Dwell Time in

Ophthalmology Clinics

N 114Mean (minutes) 22.64Standard Deviation(minutes) 61.37

*N does not include patients admitted to the hospital directly from clinic.

Study DesignSix outpatient areas participated in

this study, all of which performed infu-sions on a regular basis. The areasincluded the Digestive Health InfusionCenter, Cancer Center Infusion Center,Outpatient Surgery Center, UrologyOutpatient Surgery, Pediatric InfusionCenter, and the Ophthalmology Clinic.Data were collected over a four-weekperiod in each of these areas to deter-mine the volume of PIVs inserted anddwell times of each.

Analysis

CostOver a four-week period, 1,018

PIVs were inserted in the study areas.The estimated cost of gauze and tapewas $0.02 per IV, and the cost ofVersaderm was $0.64 per PIV.

restart). Further study is recommendedto compare the quality of the differentPIV dressing methods.

Next StepsOutpatient nursing practice has

expanded with the migration of manyprocedures and infusions that wereonce performed in the inpatient set-ting. Outpatient nurses and clinicianresearchers need to examine best prac-tice and evidence-based research to

ensure that current practice standardsare efficient and effective for the outpa-tient setting. Ongoing investigationshould be done to replicate inpatient-based research to ensure that it is cost-effective for the outpatient setting.

Pamela B. DeGuzman, MSN, RN, MBA,is the QI Analyst Programmer, UVA Heartand Vascular Center, University of VirginiaHealth System, Charlottesville, VA.

W W W . A A A C N . O R G 5

Annualizing these costs showed a differ-ence for these six areas to be $7,890(see Table 1).Dwell Time

The mean dwell time for all units inthe study was found to be 186 minutes(SD = 119 minutes). The maximumdwell time, excluding admissions, was695 minutes (see Table 2 and Figure 1).The Ophthalmology Clinic, represent-ing 11% (n = 114) of total PIVs, had sig-nificantly shorter dwell times (u = 23,SD = 61) than any of the other studyunits (ANOVA, p < 0.001). As describedby one of the clinicians, ophthalmologyinfusions are very fast and are used pri-marily to infuse sodium fluorescein forangiography of the eye. The PIV is leftin for about 20 minutes for emergencyaccess in case the patient has anadverse reaction to the medication infu-sion, even though the injection itselfonly takes about 2 to 3 minutes (seeTable 3 and Figure 2).

ConclusionThe study demonstrated that the

cost of changing products, at less than$10,000 yearly for the six areas studied,was relatively minor compared with theoverall expense of running the outpa-tient clinics. The outpatient dwell timeswere significantly different than the2.45 days described in the literature asconsistent with inpatient dwell times.The Ophthalmology Clinic’s dwell timeswere even shorter. This information wasshared with the institutional practicecouncil. They concluded that eventhough changing product had a rela-tively minor cost increase, there was nocompelling reason to implement achange in PIV practices in ambulatorycare. The recommendation by theauthors was that the outpatient areas(clinics, outpatient surgery, radiology)use the sterile gauze and tape methodfor PIVs with dwell times less than 12hours. It was also recommended thatVersaderm be used for infusions requir-ing site visualization, such as usinghighly toxic substances for chemother-apy or short-term surgical procedures.While this study provides good evi-dence of the cot effectiveness of the PIVdressing practices, it did not addressthe effect on the quality of patient carespecifically associated with complica-tions related to catheter movement (forexample, dislodging the catheter, infil-tration, disconnection, and the need to

Figure 1.Histogram for Dwell Time in All Ambulatory Units

Figure 2.Histogram for Dwell Time in Ophthalmology Clinics

continued on page 13

Member Get-a-MemberRecruitment Underway

The annual Member-Get-a-Membercampaign kicked off during the AAACNAnnual Conference in April. As a memberof AAACN, you are already enjoying thebenefits of membership, and it should beeasy for you to promote membership toyour colleagues. Consider sharing yourcopy of Viewpoint, pointing out the con-tinuing nursing education features, aswell as the other informative articles andnews about the ambulatory and tele-health community. Explain that as amember, your colleague could participatein live audio seminars, apply for an awardor scholarship, receive our monthly E-newsletter, and network with other nurs-es in our seven Special Interest Groups.

Be the AAACN member who recruitsthe most new members (6 or more) andreceive paid registration, super-saver air-fare (maximum of $400), and 3 nightslodging at the headquarters hotel (dou-ble occupancy) at the 2009 AnnualConference, March 26-30, inPhiladelphia, PA. Any member recruiting3 or more new members will receive acertificate worth $100 off future AAACNeducational programs or resources. Fivemembers who recruit at least one newmember will be entered into a drawing tohave their membership renewed for oneyear. To qualify, make sure the colleaguesyou recruit fill in your name on the “Whoreferred you to AAACN?” line on the mem-bership application. Download the appli-cation at www.aaacn.org, or call theNational Office at 800-262-6877 torequest a supply of applications.

Congratulations!The following 35 AAACN members

achieved Ambulatory Care NursingCertification at the Chicago conference.

Clinical ExcellenceAward Winner

Sharon Thompson, MSN, RN,C, was thewinner of the Clinical Excellence Award at the2008 conference in Chicago. Sharon wasnominated by her colleagues for her clinicalexpertise, authoring a database tracking sys-tem, training providers on Preventive HealthAssessment documentation standards, pio-neering an appointment template that savedprovider hours, authored an efficient pre-appointment record review process, andimplemented the Air Force Surgeon General'snew Preventive Health Assessment policy fivemonths early. Another colleague describedCarol as an unparalleled educator who imple-mented a weight loss class, developed a toolfor documenting preventive care in the AirForce's electronic medical record, and devel-oped training materials on electronic man-agement of this documentation.

Aside from her workday, Carol per-formed blood pressure screenings at a church-based Health fair, spearheaded a holidayclothing drive for the homeless, deliveredSummertime Heat safety briefings, providedmedical support for a military base openhouse, awards her teammates hard work byproviding lunch monthly, and while driving towork one day, rendered care to a woman hav-ing a seizure at a local bus stop! Carol's col-leagues recognized her for her impact on theirfacility, on the United States Air Force pro-grams and procedures, and how she strives tomake the work environment better. Viewpoint apologizes for omitting Sharon's photo from theMay/June conference issue of Viewpoint.

Diana AlemarRosamma AlexanderElena E. ArushanyanNancy L. BarrMichelle L. BelvilleJanice A. BestChristine BollierThomas G

BrockmannDeborah M. Byrne-

BartaMartha Lynn

ComstockLinda A. CordoniMaryrose CoughlinAlecia R. CuellarDeborah A.

DannemeyerMargaret M. DyerNorman F. Glover

Mary ElizabethGreenberg

Jane A. HummerMeranda A. JenkinsCynthia J. JensenDeborah L KallistoPhillip G. KleinmanLinda P. LancasterSusan Mary LehtoMonica M. MauzeyLisa E. MonteleoneAudra L. PierceDonna M StarsiakJacqueline J. StubbeTeresa M. W. TerryMichael G. TurturroPaula M. WintersShanna B. WolfJanine M. YatesAlexa E. Yohn

6 V I EWPO I NT J U LY /AUGU ST 2008

AAACNN E W S

If you would like to join this elitegroup and are planning to attend theAAACN Annual Conference, March 26-30, 2009, in Philadelphia, the exam willbe offered at the close of the conferenceon Sunday, March 29, 2009, at 2:30 p.m.

September Live Audio SeminarDate: September 23Time: 10:00 a.m. Pacific/11:00 a.m. Mountain

12:00 p.m. Central/1:00 p.m. EasternTopic: Communication: One Solution to Health LiteracyCNE Credit: 1.25 contact hoursPresenter: Cheryl Oliver, RN, BSN, BC, CPE, Nurse Educator,

Kelsey-Seybold ClinicYou may download the registration form from the AAACN Web site (www.aaacn.org)

or call 800-262-6877 to request a registration form.From an ambulatory care nurse’s view – How can we impact the Health

Literacy Issue from the moment of the patient care office visit? The most workableanswer is, “With effective communication.” This one-hour live audio seminar willbring to the forefront of the participant’s thought process: How can I better com-municate with my patients to receive better compliance? The presenter will brieflydiscuss how to communicate with any individual regardless of the level of literacy.

Member Price: $99 Regular Price: $129

Recorded Seminar and Handout on CD-ROM:Member Price: $109 Regular Price: $139 other

Membership Promotion CD Available

A complimentary CD explaining thebenefits of membership in AAACN is avail-able from the National Office. If you wouldlike to promote membership in AAACN toa group of colleagues, please contactAAACN Association Services Manager PatReichart at reichartp@ajj.com or 800-262-6877, ext. 3, to request a copy. We are alsohappy to supply you with product flyers,membership applications, samples ofAAACN Viewpoint, and other promotionalmaterials.

Capt. Sharon Thompson (left) receives the ClinicalExcellence Award from Cyndee Hnatiuk, Executive VPof A. J. Jannetti, Inc., sponsor of the award

W W W . A A A C N . O R G 7

PProviding a platform to build those part-

nerships, Nursing Economic$ journal will hostthe 2nd Annual Nurse Faculty/Nurse ExecutiveSummit, December 4-6, 2008, at the HyattRegency Scottsdale Resort and Spa at GaineyRanch, Scottsdale, AZ. More than 400 nursingleaders, executives, educators, deans, admin-istrators, and other decision makers from hos-pitals and schools of nursing are expected toattend this innovative Summit. Building onthe success of last year’s Summit, additionaldialogue time has been built into the three-day schedule to promote open and provoca-tive discussions.

Attendees will hear from leading healthcare experts on such topics as the future ofnursing, health care reform, sustaining part-nerships, quality and safety education, and

practice development. In addition to educa-tion sessions, participants will network withcolleagues during the dynamic poster ses-sions, earn continuing nursing education cred-its, and meet with leading publishers, hospi-tals, schools of nursing, and educators in theexhibit hall. More information, online registra-tion, and a call for posters are available atwww.nursingeconomics.net.

RegistrationComplete conference registration infor-

mation and online registration are available onthe Nursing Economic$ Web site, www.nursingeconomics.net. For additionalinformation, contact Nursing Economic$ at856-256-2300 or e-mail nejrnl@ajj.com.

Nursing Economic$ Hosts Second Annual Summit

December 4-6, 2008 – Scottsdale, Arizona This meeting will provide a forum to develop strategic partnerships, key to building the nursing profession.

Continuing Nursing EducationThis offering, sponsored by Anthony J.

Jannetti, Inc., offers up to 16 contact hours. Anthony J. Jannetti, Inc. is accredited as a

provider of continuing nursing education bythe American Nurses Credentialing CenterCommission on Accreditation (ANCC-COA).

Anthony J. Jannetti, Inc. is a providerapproved by the California Board ofRegistered Nursing, CEP5387.

About Nursing Economic$Nursing Economic$, The Journal for Health

Care Leaders is a valuable resource for nurseexecutives and faculty, publishing a wide vari-ety of articles that aim to advance nursingleadership in health care by providing infor-mation on current and emerging best prac-tices. AAACN members have the option ofreceiving Nursing Economic$ as a memberbenefit of AAACN.

Can’t we all just get along? That old adage holds true fornurse faculty and nurse executives, who in a rapidly changinghealth care environment must work together and build strongpartnerships to ease the challenges ahead.

When you are contributing to a cause you believe in, it’s easy to build on the

cumulative energy and dedication of those around you. This camaraderie is

one of the things that drives my work at Kaiser Permanente. Working together,

my colleagues and I share the same mission to make a positive difference in

people’s lives. We know that each goal we reach brings us one step closer to

the next—and to each other. If you believe success is richer when shared, this

is the place to put your beliefs into practice.

WE ARE PROUD TO BE AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER.

Kaiser Permanente is the nation’s leading nonprofit integrated health plan and a recognized health advocate. Our every action

supports the well-being of the men, women, and children who depend on us for care. All 8.7 million of them in California, Colorado,

the District of Columbia, Georgia, Hawaii, Maryland, Ohio, Oregon, Virginia, and Washington. For more information about

nursing opportunities with Kaiser Permanente, e-mail us at rnrecruit@kp.org or visit our Web site.

kp.org/jobs/nursing2008

let’s move forward together

8 V I EWPO I NT J U LY /AUGU ST 2008

work, which are those that foster supportive relationshipsbetween co-workers and with employers, where nurses areproperly compensated and resourced, as well as haveenough time to render proper client care, are consideredhigh-quality workplaces.

Nursing retention is directly related to the quality of theworkplace. Health Link Alberta, Canada, is such a work-place. It is a publicly funded provincial nurse advice line thatoperates from two sites under a regionalized and integratedhealth system, serving a population of approximately 3.4million people. These call centers provide telehealth andhealth information, and receive over 1 million calls per year.Health Link Alberta serves several cities as well as a constel-lation of smaller communities and numerous rural areas.The landmass covered stretches from mountains to prairies,nearly equal in size to the state of Texas with a populationsimilar to that of Oregon.

Health Link Alberta reviewed the literature and identifieda three-point framework that is now used to examine work-place facilitators and barriers. These workplace characteristicscontribute to the quality of the telecare work environmentand have the potential to impact nursing retention.

Clinical Engagement/Professional PracticeResearch has shown that when nurses feel valued in

their practice environment by nursing administration, thereis a statistically significant effect seen on the nurses’ level ofsatisfaction or clinical engagement. According to Mercerand Couturier (2008), clinical engagement refers to takingownership of the changes that occur in personal practiceand developing the ability to define and drive changes thatbenefit both nurses and clients. It involves communities ofpractice, affects organizations as a whole, and necessitatescollaboration with others. Clinical engagement in the callcenter can begin by creating working groups to involvenurses in decision making, having them critique protocolsand policies, providing nurses a career development pro-gram for knowledge updates and career progression, facili-tating support from professional associations, supportingcolleagues to balance work and family, and recognizingefforts and accomplishments of staff. Identified barriers toclinical engagement include poor communication, lowmorale, lack of trust and respect, and little involvement ofemployees in decision making (Domm et al., 2007).

Nurses and nurse managers need to consider ways toengage themselves and their co-workers daily. Ideally, clini-cal engagement should begin from the onset of theemployment relationship. A key piece to nurse retention ishiring the right nurse for the job. Behavior-based hiringtechniques and offering potential hires realistic job previewscan help facilitate this.

Health Link Alberta provides new nurse employees acomprehensive, month-long group orientation program,stresses personal attention, and works hard to foster a senseof belonging to the call center family. Even before new staffarrive for their first day, the leadership of Calgary Health Link

starts to create an inclusive environment. The clinical nurseeducator phones new recruits at home to personally wel-come them and supplies the information they need toreduce stress and gain a foothold in their new work environ-ment prior to orientation. New nurses to the call center aregreeted at the door by management, and a welcome cardfrom the leadership team awaits them on day one.Experienced call center staff sponsor a potluck lunch, andstaff are encouraged to invite new staff to coffee breaks withthem throughout the orientation period. But perhaps thegreatest impact on new nurses is being “buddied up” witha nursing preceptor or mentor. Health Link preceptors workside by side with new recruits functioning as valuableresources and role models, developing a one-to-one rela-tionship, while socializing nurses to the call center. The pre-ceptor program creates a less-stressful transitional period fornew staff. Preceptors foster independence, develop skills,provide role modeling, and promote socialization, all whiledeveloping confidence and competence in those who arenew to the telehealth role (Daigle, 2001).

Health Link administration has acknowledged that careshould be taken in the selection of preceptors. To serve asan effective role model who can facilitate positive learningto occur, a preceptor must not only be an experienced tele-health nurse, but he or she must also possess a positive atti-tude. An experienced telehealth nurse with a jaded attitudecan be dangerous to any nursing preceptor program.Calgary Health Link preceptors are recognized and support-ed by nursing administration because teaching new staff isa profound responsibility and can be stressful. All nurseshave monthly quality call audits. This allows leadership tocheck in with staff on a regular basis to ensure they arereceiving the training and support they need to feel goodabout the job. Nurse leaders who can create this type oftrustful and empowering environment may expect to findstaff nurses’ perceptions of job satisfaction levels increased.

Communication/Workplace CultureLiterature suggests a second theme or framework;

social climate of the workplace can also be a predictor of anurses’ intent to stay or leave. Social climate is a determi-nant of work frustration and work excitement, and directlyinfluences job stress and level of job satisfaction. Job satisfac-tion, or more pointedly, job dissatisfaction, is the strongestpredictor of intent to leave a job (Atencio, Cohen, &Gorenberg 2003). Workplace characteristics, such as a com-munication-rich culture, increased nurse autonomy, flexibil-ity of managers, ability to control schedule as much as pos-sible, competitive compensation, and working with anappropriate scope of practice, are facilitators of a positivesocial climate. Barriers include rigidity of management poli-cies, heavy reliance on overtime instead of hiring neededstaff, lack of required resources, perceived pay inequities, lit-tle nursing autonomy, and poor communication practices(Donn et al., 2007).

Nursing leaders must maintain an open dialogue withstaff and continually ask what systems need improvement,and what material resources or technical equipment areneeded to improve working conditions. Staff nurses should

Hole in the Bucketcontinued from page 1

W W W . A A A C N . O R G 9

participate in systems problem-solving. An analysis of 3,000nurses who stated they intended to stay in or leave their cur-rent position showed 40% of the time, the organization coulddo something about the intention to leave, namely byaddressing issues of job characteristics (“hassles” limited tosystem issue), schedules, team dynamics, leadership, com-munication, and professional development (Gagnon et al.,2006).

Call centers want their nurses to look forward to comingto work rather than dread it. Initiating a program that pro-motes having fun in the workplace is an invaluable retentiontool. Gallup poll research shows that the “best friend” phe-nomenon is a major predictor of successful teamwork and anextremely powerful indicator of workplace engagement(Blizzard, 2002). The one key piece to developing a groupcohesion retention program is that staff nurses must play anactive role in designing the program.

Simple suggestions that call centers could implement toincrease the ‘fun’ at work include:

• Causal Fridays, where staff can wear jeans to work.• Theme days, such as Hawaiian day, Derby day, or pajama

day.• Unit-sponsored tea parties, potlucks.• Themed coffee or refreshment break, such as yoga and

yogurt.

Celebrate and acknowledge nurses’ special days as wellas the good work they do (see Figures 1 and 2). The callcenter encourages staff to share their passions with oneanother outside of work as well. This has led to call centerurban hikes, a golf tournament, and gourmet cooking class-es, and book club and movie nights. All staff members areinvited to participate in these events, which foster cama-raderie and encourage co-worker relations. The call centerhas also begun a wellness initiative. As part of this program,students from a nearby massage college have been invitedto come to the call center and provide neck/shoulder mas-sages to nurse agent staff on breaks. This provides the mas-sage students with practicum experience and is a win-winsituation for all involved. Unit subscriptions to severalhealth, fitness, and cooking magazines, as well as a healthlending library filled with books and CDs, have also beenstarted. Whether it takes the form of a flexible work environ-ment, continuing education classes, heartfelt appreciation,or increased nursing autonomy, strategies that enhancework morale and performance decrease turnover. Call cen-ters may be able to vastly improve engagement levels byemphasizing a sense of teamwork and a strong sense ofcamaraderie.

LeadershipBratt, Broome, Kelber, and Lostocco (2000) describe a

positive association between job satisfaction and nursingleadership. Management strategies empowering nurses toperform their job effectively are strongly correlated to jobcontentment. A positive perception of nurse managers’leadership has been shown to differentiate nurses whointend to stay from those who intend to leave. Indeed, oneof the top job characteristics nurses need to be happy ishaving good nursing leadership. Retention efforts targetedtoward management strategies need to be put into dailypractice to ensure a positive perception of nurse managers’leadership. Nurse leaders need to have a regular presence intheir call centers. Leaders need to be approachable, and callcenters must invest in developing nurse managers’ leader-ship skills and support their abilities to positively impact staffnurses’ perceptions and psychological experiences at work.

To increase the positive perception of nurse managers’leadership, managers must focus on developmental issues,such as managing performance issues, involving others indecision making, communicating a long-term vision, mak-ing clear and specific plans, delegating adequately, and giv-ing performance feedback (Gagnon et al. 2006). Toincrease job satisfaction, leaders should focus on profession-al support and recognition. Not only do managers need torecognize top performers, low performers must also beidentified immediately and addressed since they can have adramatic effect on call center morale.

At Calgary Health Link, nursing leadership has chosento make a serious commitment to call center dynamics andcreate an environment where nurses want to work. To thatend, leadership commissioned staff nurse surveys asking forfeedback on issues affecting call center retention and effi-ciency. Exit interviews are also conducted to help under-stand nurses’ perceptions. Identified areas of quality

Figure 1.

Gloria Dix of Health Link Alberta, Calgary Site, takes advantage ofHawaiian Day.

Figure 2.

At Health Link Alberta, Calgary Site, experienced staff member Lori Fecho(right) works with new staff member Brenda Kobberstad-Kwan.

10 V I EWPO I NT J U LY /AUGU ST 2008

improvement are now being addressed on a regular basis.Ergonomic assessments have been done, and modifiedworkstations and equipment are available for staff. Staffnurses have been placed on hiring panels, and career ladderand career development pathways have been clearly laidout. Leadership behaviors that foster staff nurses participa-tion in decision making have been reinforced.

An issue management process is a mechanism for shar-ing ideas and ensuring that accurate information is relayedto callers. Monthly call audits are done for nurses by thequality assurance team, and management has committed toyearly performance conversations with each staff member.Long-term vision and call center business is shared with staffat regularly held staff meetings and through intranet mes-saging. Open, frank dialogue with nurses and managers issupported in this environment, and during each staff meet-ing, staff are asked to share any “gripes or grapevine” items,allowing management to deal with these issues early andmore easily. Executive Director Lori Anderson states that she“sometimes offers a prize for the best rumor at staff meet-ings.”

Heartfelt appreciation and recognition is given to staff,both in person and through the CARE (Congratulating andRecognizing Efforts) program. CARE is based on a simplethank you note strategy, as day-to-day recognition is one ofthe most highly valued forms of recognition. It is a processthat encourages positive feedback and allows call centeremployees an opportunity to thank one another in a spon-

taneous and meaningful way. Anyone can pick up a carenote and share a message of thanks. The top copy is givento the recipient; the bottom copy is placed in the care boxfor review by the care team for consideration for a recogni-tion package. Health Link Alberta’s retention efforts are awork in progress. Staff and management are constantlylooking for new, innovative ways to improve the call center,making it a high-quality workplace where all truly enjoycoming to work.

ConclusionCalgary Health Link’s Nurse Manager Lara Mazzei

acknowledges, “Nurses need to see and feel support fromtheir administrative team, as well as feel challenged in theircareer and be offered growth opportunities. You have toknow what inspires your nurses to stay in the call centerenvironment and why some choose to leave it.” She feelsthat by involving her nurses in the design and operations ofthe call center in clinical, educational, and research roles asmuch as possible, while providing career development path-ways, has had a significant effect on nurse’s satisfaction lev-els. Health Link Alberta acknowledges that its call centernurses want to be appreciated, respected, and recognizedby the administrative team. There is no apparent end insight to the international nursing shortage in the foreseeablefuture. Nursing retention is perhaps a more important issuenow than ever before in the history of nursing. Nursing callcenters must take a serious look at its retention efforts and

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You will thrive in an environment that provides the opportunity to workwith innovative colleagues and the very latest of technologies. And because we’re also a teaching hospital, you’ll find all the resources andtools to help you succeed at every level of your development.

You’ll be joining a facility that is well-recognized for its excellence—exemplified by Consumer Reports ranking us in the nation’s Top 3 forconservative patient care, which results in patients spending fewerdays in the hospital, fewer days in an intensive care unit, with fewerphysician visits and a greater reliance on your nursing insights.

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W W W . A A A C N . O R G 1 1

Earn 1.4 Contact HoursThere Is a Hole In the Bucket –

Nursing Retention Strategies Used In a Large Canadian Call Center

To Obtain CNE Credit1. For those wishing to obtain CNE credit, please use the evaluation

form inserted in this newsletter, or visit the AAACN Web site(www.aaacn.org). Read the article and complete the answer/evalu-ation form.

2. Photocopy and send the answer/evaluation form along with yourcredit card payment or check ($15 members/$20 non-members)payable to AAACN, East Holly Avenue Box 56, Pitman, NJ 08071-0056.

3. Evaluation forms must be postmarked by August 31, 2010. Uponcompletion of the answer/evaluation form, a certificate for 1.4 con-tact hour(s) will be awarded and sent to you.

ObjectivesThe purpose of this continuing nursing education article is toincrease the awareness of nursing retention strategies. After study-ing the information presented in this article, you will be able to:1. Define “clinical engagement” and how it relates to nurse reten-

tion.2. Explain the benefits of communication in the workplace.3. Discuss the ways nurse managers can lead their staff and ensure

a positive perception.Note: The authors, editor, and Editorial Board reported no actual orpotential conflict of interest in relation to this continuing nursingeducation article.

This educational activity has been co-provided by AAACN and Anthony J.Jannetti, Inc.

Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursingeducation by the American Nurses’ Credentialing Center’s Commission onAccreditation (ANCC-COA).

AAACN is a provider approved by the California Board of RegisteredNurses, provider number CEP 5336. Licenses in the state of CA must retain thiscertificate for four years after the CE activity is completed.

These articles were reviewed and formatted for contact hour credit byValerie Leek, MSN, RNC-NIC, CMSRN, AAACN Education Director; andRebecca Linn Pyle, MS, RN, Editor.

and colleague; to Beth Ann Swan for co-editing theAmbulatory Care Nurse Staffing: An Annotated Bibliographyand co-authoring articles for Nursing Economic$ with me; toSusan Pashke for her support and understanding; to PegMastal for being an inspiration and her leadership in updat-ing the standards; to E. Mary Johnson for her friendship andcalling me the night before my surgery to offer words ofcomfort and support; to the current Board of Directors andpast Board members – know that you helped the organiza-tion grow and knowing you has made my life richer; to theleadership group and tasks force members – I thank you foryour dedication and time you freely give to AAACN; and toour membership, for without you, we would not be anorganization. Many ambulatory care nurses do not identify

themselves as such. We need to actively work in getting theword out to colleagues about who we are and what we do.

Do you have a story to share? If so, please contact NancySpahr, MS, RN,C, MBA, CNS, who writes the “Real Nurses,Real Issues, Real Solutions” column that appears in each issueof Viewpoint. Nancy highlights AAACN members by lookingat the types of ambulatory care roles they fill, their day-to-daychallenges, their reasons for joining AAACN, and howAAACN membership has helped them as professional ambu-latory care nurses. See page 14 to learn more about two ofyour AAACN colleagues and for details on how to submityour story!

Karen Griffin, MSN, RN, CNAA, is Associate Chief, Nursing ServiceAmbulatory Care, South Texas Veterans Healthcare Systems, SanAntonio, TX. She may be contacted via e-mail at kfgriffin@hotmail.com

President’s Messagecontinued from page 2

develop retention plans. When your bucket is leaky, it’s fool-ish to continually go back to the well. Now is the time todecide how to patch the holes in the bucket.

Patricia Chambers, BHScN, RN, DC, is the Acting Team Leader,Health Link Alberta, Calgary Site, Alberta, Canada.

Lara Mazzei, BScN, RN, is a Manager, Health Link Alberta,Calgary Site, Alberta, Canada.

Note: This article is based on an in-brief session presented duringthe AAACN Annual Conference in Chicago, IL, April 20, 2008.

ReferencesAtencio, B., Cohen, J., & Gorenberg, B. (2003). Nurse retention: Is it

worth it? Nursing Economics, 21(6), 262-268.Blizzard, R. (2002). Nursing: The rules of engagement, part II. Health

and healthcare. Retrieved July 22, 2008, from http://www.gallup.com/poll/5374/nursing-rules-engagement-part.aspx

Bratt, M., Broome, M., Kelber, S., & Lostocco, L. (2000). Influence ofstress and Nursing leadership on job satisfaction of pediatricintensive care unit nurses. American Journal of Critical Care, 9(5),307-317.

Daigle, J. (2001). Preceptors in nursing education – Facilitating stu-dent learning. Kansas Nurse, 76(4), 3-5.

Domm, E., Smadu, M., & Eisler, K. (2007). Developing high-qualityhealth-care workplaces: Facilitators and barriers. Canadian Nurse,103(9), 11-12.

Gagnon, S., Ritchie, J., Lynch, A., Drouin, S., Cass, V., Rinfret, N., et al.(2006). Job satisfaction and retention of nursing staff: The impact ofnurse management leadership. Canadian Health Services ResearchFoundation. Retrieved July 22, 2008, from http://www.chsrf.ca/final_research/ogc/gagnon_2_e.php

Mercer, C., & Couturier, C. (2008).The five Ws of clinical engage-ment. Canadian Nurse, 104(5), 9-10.

Robinson, M. (2008). Closing perspectives: RN shortage needs a bal-anced approach. Alberta RN, 64(1), 46.

12 V I EWPO I NT J U LY /AUGU ST 2008

eracy to improve their communication skills with patients.Both concepts would help standardize communication in thepatient’s native language. It would also discourage the use ofuntrained personnel or family members for interpretation ofmedical information (Ku & Flores, 2005).

In the book, Hospitals, Language and Culture: A Snapshotof the Nation Exploring Cultural and Linguistic Services to theNation’s Hospitals, Wilson-Stronks and Galvez (2008) note that90% of hospitals reported a financial strain secondary to theprovision of interpreter services. However, other organizationsreported that they had or were planning to implement inter-preter programs, have organized diversity fairs, and weredeveloping programs on cultural diversity to augment currentservices. In some organizations, the first encounter interviewhas been expanded to include race, ethnicity, primary lan-guage for both patient and family, religion, and educationalbackground. It is anticipated this will better enable providersto plan for educational needs and potential barriers to learn-ing. Many organizations report the use of standardized infor-mation sources, such as Micromedex, CareNotes, PubMed,MedlinePLUS, and OVID Medline, to assist in the educationprocess and provide a consistent approach to materials.

At the University of Rochester, an interdisciplinary groupcomposed of representatives from nursing, medical staff, phar-macy, radiology, occupational therapy, speech therapy, physi-

cal therapy, pastoral care, and utilization review managementhas started to use the form to document patient education. Inplanning educational efforts, attention should also be given tothe creation of clear signage, the use of simple forms, and theidentification of communication barriers that may existbetween health care providers, patients, and their families.

The Healthy People 2010 Web site (http://www.healthy-people.gov) with the assistance of the National Library ofMedicine and the Public Health Foundation, provides informa-tion on health literacy and evidence-based strategies for inter-vention. These one-click strategies search PubMed, a databaseof the National Library of Medicine, to provide access to over11 million citations from MEDLINE and other life science jour-nals. PubMed provides links to abstracts and/or full text articles.This site is a pilot project funded through the National Libraryof Medicine, with assistance from the Public Health Foundationand the National Network of Libraries of Medicine. Future proj-ects include the expansion of searches to cover all HealthyPeople 2010 focus areas.

As ambulatory care nurses identify the areas of concern forpatients and their families, these options will help begin theprocess of meeting the information needs of their specific pop-ulation. A future article in this series will provide examples ofhow to implement a health literacy project.

Kathleen Sklenar, RN, is a Staff Nurse – Ambulatory Medicine,University of Rochester, Rochester, NY.

ReferencesIowa Healthcare Collaborative. (2003). Health literacy. Retrieved July 22,

2008, from http://www.ihconline.org/toolkits/healthliteracy.cfmKu, L., & Flores, G. (2005). Pay now or pay later: Providing interpreter

services in health care. Health Affairs, 24(2), 435-444.The Joint Commission. (2002). Speak up program. Retrieved July 22,

2008, from http://www.jointcommission.org/GeneralPublic/Speak+Up/about_speakup.htm

The Joint Commission. (2007). ‘What did the doctor say?’ Improvinghealth literacy to protect patient safety. Retrieved July 22, 2008,from http://www.jointcommission.org/NR/rdonlyres/F53D5057-5349-4391-9DB9-E7F086873D46/0/health_literacy_exec_sum-mary.pdf

University of Virginia Health Care System. (2008). Building a health lit-eracy curriculum. Retrieved July 22, 2008, from http://www.healthsystem.virginia.edu/internet/som-hlc/home.cfm

U.S. Department of Health and Human Services. (2008). Plain lan-guage: A promising strategy for clearly communicating health infor-mation and improving health literacy. Retrieved July 22, 2008, fromwww.health.gov/communication/literacy/plainlanguage/PlainLanguage.htm

Wilson-Stronks, A., & Galvez, E. (2008). Hospitals, language, and cul-ture: A snapshot of the nation: Exploring cultural and linguistic serv-ices in the nation’s hospitals. Retrieved July 22, 2008, fromhttp://www.jointcommission.org/PatientSafety/HLC/

Additional ReadingPfizer Clear Communication Initiative. (2006). Tips for improving commu-

nication with your patients. Retrieved July 22, 2008, from http://www.pfizerhealthliteracy.com/public-health-professionals/tips-for-providers.html

American Academy of Ambulatory Care Nursing

Customer Care Dept.: 888-884-8242E-mail: info@healthecareers.com

www.aaacn.org(Click on the “Jobs” tab)

The perfect solution if you are looking fora job or a nurse to complete your staff.

The AAACN Career Center is a proud memberof the HEALTHeCAREERS Network of healthcare association online career centers.

Health Literacycontinued from page 3

All educational activities promoted in this publication have been co-provided by AAACN and Anthony J.Jannetti, Inc. unless otherwise noted.

Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses’Credentialing Center’s Commission on Accreditation (ANCC-COA).

AAACN is a provider approved by the California Board of Registered Nurses, provider number CEP 5336.Licenses in the state of CA must retain this certificate for four years after the CE activity is completed.

These articles were reviewed and formatted for contact hour credit by Valerie Leek, MSN, RNC-NIC, CMSRN,AAACN Education Director; and Rebecca Linn Pyle, MS, RN, Editor.

W W W . A A A C N . O R G 1 3

Show that you are an ambulatory care nurse bywearing a tee shirt with the “Ambulatory CareNurses are Everywhere Caring for You” logo on theback and AAACN on the pocket area. Forest greentee shirts are Jerzees brand and contain 50% cottonand 50% polyester. Sizes M-2X are $10 each.

Cynthia McCaskill, BSN, RN, is the Clinician III, Surgical AdmissionSuite, University of Virginia Health System, Charlottesville, VA

Note: The authors would like to thank Suzanne M. Burns, MSN,RN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP, Professor of Nursing,for her support and mentoring.

ReferencesNicoll, L.H., & Ambler, K.E. (2005). CDC guidelines for peripheral intra-

venous therapy (1982) revisited: An integrative review of the liter-ature. The Online Journal of Knowledge Synthesis for Nursing, 2(1).

Royer, T. (2003). Improving short peripheral IV outcomes: A clinicaltrial of two securement methods. Journal of the Association forVascular Access, 8(4), 45-48.

Winfield, C., et al. (2007). Evidence: The first word in safe IV practice.American Nurse Today, 2(5), 31-33.

Evaluating Peripheral IVcontinued from page 5

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14 V I EWPO I NT J U LY /AUGU ST 2008

The AAACN spotlight focuses this month on an ambula-tory nurse who has finally found her “perfect job.” CarolAnn Attwood, MLS, AHIP, MPH, RN, C, is the medical librar-ian in the Patient and Health Education Library at the MayoClinic in Scottsdale, Arizona.

Carol Ann entered into nursingas a second career after completingan undergraduate degree in specialeducation and being unable to find ajob. Born into a family of nurses(mother and sister), she recalls tellingneighbors as a child that she “defi-nitely did not want to be a nurse withall that blood and stuff around.” Thiswas her perception of nursing sinceher mother was a surgical nurse, andthen Director of Nursing at a small rural hospital inMichigan. Returning to school, she became a registerednurse and taught as a clinical nursing instructor at the hos-pital where she trained. Realizing that a future of snow andcold was not for her, she moved to Arizona to warm up andto begin her nursing career. She has worked clinically in avariety of health care settings, including gerontology, ortho-pedics, medical-surgical, cardiovascular, and primary carenursing/triage. Along her nursing journey, she has worked inhealth care organizations in retirement communities, inner-city settings, suburban clinics, and mental health settings.

She was one of the “original” nurses at Mayo Clinic inArizona when it first opened, and she assisted other nursingprofessionals to build specialty care practices from theground up. Always a consummate learner, Carol Ann contin-ued her education and pursued masters degrees in bothpublic health and medical librarianship, while pursuing cer-tifications in occupational health, ambulatory care, and tele-phone triage nursing.

Never one to spend too long in one place, she hasworked in her current organization assisting in wellness pro-grams, primary care, quality management, and research.Carol Ann notes, “I’ve now found the perfect nursing nichefor me, that of a medical librarian in a consumer health cen-ter, where I can use all of my skills as an educator, nurse, andlibrarian to assist patients and their families to find reliablehealth care information that will assist them through theirhealth care journey. A typical day might entail research forpatients on a rare or unusual disease; assistance in findingresources in the community; teaching patrons how to findreliable, up-to-date health-related Web sites; or working oncollection development that incorporates a focus on findingthe right materials for the right patients at the right time.”In addition to managing the consumer health center, sheparticipates in ambulatory nursing workgroups, assists in theorganization’s LiveWell program, writes for the Vital Link

REA

L (Mayo’s nursing newsletter), and creates monthly displayson health care topics.

“Never a boring day”, she notes. When patrons ask herhow she knows so much, she replies, “It’s not that I know somuch, it’s knowing where to find the information thatcounts!”

Prompted to join AAACN by a nursing colleague, CarolAnn explains, “I was looking for a professional organizationthat would meet the myriad needs of nurses working in theambulatory settings to share best practices and to network;AAACN provided all that and more.” A member since 2003,Carol Ann has worked as Chair of the Patient EducationSpecial Interest Group, written for AAACN Viewpoint, pre-sented at AAACN’s annual conferences, and is now a part ofthe 2009 Annual Conference Program Planning Committee.She has utilized many AAACN resources to prepare for hercertification examinations in ambulatory and telehealthnursing. Carol Ann would like to encourage her nursing col-leagues to study and take the ambulatory certification exam-ination. She writes, “It is a great sense of satisfaction know-ing you are a certified ambulatory care nurse.”

Carol Ann notes that she enjoys the ambulatory care set-ting because of the “amazing diversity of experiences,opportunities to learn, and colleagues that remain not onlyclinical resources but also trusted friends. I couldn’t imagineany other place to work that is a constant challenge in criti-cal thinking as nurses prioritize, assess, plan, and work toimprove access and delivery of health care to different ages,ethnic backgrounds, and educational levels. I love to gohome every day feeling as if I made a difference in the livesof the patients, family members, and staff that I encounter –whether it is shared information, emotional support as anew diagnosis is given, or mentoring my colleagues.”

Don’t assume, however, that Carol Ann is nearing theend of her nursing career. Initiatives that she still wishes topursue are health literacy efforts and outreach to under-served communities, working until her twins are finishedwith college (at least another decade!), and working onmedical missions around the world. And if she has any sparetime, perhaps she’ll take a few more classes. Nursing hasbeen the absolute best profession for her!

AAACN is proud to highlightanother ambulatory nurse who hasfound her passion in helping peoplecope with chronic illnesses. MeetRoslyn Kelly, BSN, RN, BC, CDE, whoworks for the Baltimore VeteransAdministration Primary Care Clinic asan ambulatory nurse and diabetesnurse educator. She also works part-time for Kaiser Permanente UrgentCare and is currently attending theUniversity of Maryland School of Nursing. If all goes accord-ing to plan, Roslyn will graduate in May 2009 with a mas-ters’ degree in Nursing/Health Services in Leadership andManagement with a focus on Nursing Education.

We aren’t sure what Roslyn does in her “spare time,” butshe tells us that she also facilitates a diabetes self-manage-

CarolAnn Attwood

Roslyn Kelly

W W W . A A A C N . O R G 1 5

ment education group two times a week and helps with thehypertension, diabetes, and primary care nurse-managedclinics.

Roslyn has been a registered nurse for 13 years, and 8 ofthose years were spent serving in the U.S. Army. She is mar-ried to a retired Army veteran of 22 years. Roslyn explains, “Ihave traveled throughout the world as a veteran and as amilitary spouse, and have worked in various units anddepartments, including infectious disease, oncology, familyplanning, and primary care.”

As an active member of Sigma Theta Tau, Roslyn is agreat believer in becoming certified in your area of specialtyor interest. Since she has several areas of interest, she is cur-rently certified in ambulatory care nursing, diabetes educa-tion, and parish nursing. Hats off to you Roslyn! You haveraised the bar for all of us.

We asked Roslyn what prompted her to become a mem-ber of AAACN. She tells us, “Working for the health depart-ment and the internal medicine clinic confirmed my passionfor teaching patients how to manage their chronic illnessesand ultimately lead healthier lives. I found that I needed reli-able resources to help me transition from inpatient to ambu-latory care nursing. I also wanted to learn the standards andconceptual framework for ambulatory care nursing. I realizedthat this framework had to govern and define professionalpractice in my ambulatory care nursing role. With this inmind, I joined AAACN in 2003 to learn all I could about beingan ambulatory care nurse. This membership has been a win-win solution for me professionally as well as personally, and ithas even helped me in my informal role as a parish nurse.”

Roslyn readily admits that the best part of belonging toAAACN is the access to high-quality ambulatory resources.She uses the E-Newsletter, AAACN Viewpoint and MEDSURGNursing: The Journal of Adult Health as practice resources, andenjoys the networking that comes from membership in theSpecial Interest Groups.

Now that Roslyn has found the joys of working in theambulatory setting, we asked her what keeps her going onthose tough days in the clinics when everything doesn’t gothe way she might have planned. She explains, “On thoseespecially difficult days, I remember some of my patientswhose eyes light up when they have just learned somethingnew which will help them with their chronic illness. It is atthose times that I know I have made a difference by empow-ering them to make healthy lifestyle changes. They know Itruly care about them as individuals. My future goal is toexpand the diabetes self-management education group tofour days a week and develop a Diabetes EducationAwareness seminar for patients, families, and staff.”

Roslyn recently received the Veterans Affairs MarylandHealth Care System Award for Excellence in Nursing. Theaward was given to recognize Roslyn for her compassion,dedication, and outstanding performance in providing nurs-ing care to veterans and their families, and for supportingthe mission, philosophy, and values of the Department ofVeterans Affairs. Congratulations Roslyn!

Nancy Spahr, MS, RN,C, MBA, CNSClinical Nurse Specialist

Ambulatory Care Mayo ClinicPhoenix, AZ

Are You Taking Full AdvantageOf Your AAACN Benefits?

AAACN Is Here for YouWe’d like you to think of us as your support system, your

understanding friend, your favorite nurturing professor, yourtrusted source for ambulatory care knowledge. In this role, wewant to make sure you are aware of every benefit available toyou, as our valued member. After all, you deserve the best!

Have You Used These AAACN Benefits?

Network and grow professionally• AAACN’s Annual Conference• Web Site (www.aaacn.org): Searchable membership

directory, e-mail lists, discussion boards • Online Career Center (find or post a job)• Special Interest Groups (SIG)• Local Networking Groups (LNG)

Reap the rewards of leadership• Task forces and special committees• Positions at the national level• SIGs and LNGs• Advocacy and liaison roles

Learn and discover• Viewpoint, AAACN’s award-winning newsletter• Subscription to a leading nursing journal• Monthly e-newsletter• Continuing education programs, events, and services• Certification study tools

Special perks• Member discounts• Scholarships, research grants, and awards

Have You Articulated These Benefits to YourEmployer?

• Quality care: Staff members who access member ben-efits in a specialty nursing association such as AAACNare more educated and knowledgeable about best prac-tices.

• Magnet status support: Whether your facility is seek-ing or maintaining Magnet status, AAACN provides awealth of resources to achieve magnet standards andnurture nursing leaders.

• Patient safety: Outcomes are improved and errorsreduced with a more knowledgeable staff.

• Excellence in service delivery: More qualified nurseswill improve day-to-day operations.

• Top-quality education tools: Nurses who purchaseAAACN resources, products, and services typically sharethem with staff members.

• Board-certified nursing staff: AAACN providesstudy tools for ambulatory care nursing certification.

We welcome your questions and comments, so feel freeto contact us at 800-262-6877 or aaacn@ajj.com

Presorted StandardU.S. Postage

PAIDBellmawr, NJPermit #58

© Copyright 2008 by AAACN

Real Nurses. Real Issues. Real Solutions.

American Academy ofAmbulatory Care Nursing

Volume 30 Number 4

AAACN is the association of professional nurses and associates who identify ambulatory care practice as essentialto the continuum of accessible, high quality, and cost-effective health care. Its mission is to advance the art andscience of ambulatory care nursing.

Viewpoint is published by theAmerican Academy of Ambulatory

Care Nursing (AAACN)

AAACN Board of DirectorsPresidentKaren Griffin, MSN, RN, CNAAAssociate Chief Nursing Service, Ambulatory CareSouth Texas Veterans Healthcare Systems210-617-5300 x4152 (w)kfgriffin@hotmail.com

President-ElectKitty Shulman, MSN, NCDirector, Children’s Specialty CenterSt. Luke’s Regional Medical Center919-350-0929 (w)chawilliams@wakemed.org

Immediate Past PresidentCharlene Williams, MBA, BSN, RNC, BCDirector, WakeMed OneCallWakeMed Health and Hospitals208-381-7010 (w)millerki@slrmc.org

TreasurerTraci Haynes, MSN, RN, CENNurse Manager, Clinical ServicesMcKesson Health Solutions480-342-7048 (w)Traci.Haynes@mckesson.com

DirectorsMAJ Belinda A. Doherty, USAF, NCFlight Commander, Education and TrainingUnited States Air Force520-228-1547 (w)belindadoherty@dm.af.mil

Assanatu (Sana) I. Savage, LCDR, USNSenior Nurse OfficerUnited States Naval Training Center619-524-1309 (w)iyatutu_1@yahoo.com

Marianne Sherman, RN, C, MSClinical Standards Coordinator, AmbulatoryAmbulatory Nursing DirectorUniversity of Arkansas Medical Center501-526-5466msherman@uams.edu

Nancy Spahr, MS, RN-BC, MBA, CNSClinical Nurse Specialist, Ambulatory CareMayo Clinic Arizona480-301-6680 (w)spahr.nancy@mayo.edu

Cynthia Nowicki Hnatiuk, EdD, RN, CAEExecutive Director

Patricia ReichartAssociation Services Manager

AAACN ViewpointEast Holly Avenue, Box 56Pitman, NJ 08071-0056(800) AMB-NURS(856) 589-7463 FAXaaacn@ajj.com www.aaacn.org

EditorRebecca Linn Pyle, MS, RN

Editorial BoardLiz Greenberg, PhD, RNCVannesia D. Morgan-Smith, BSN, RN, BC, CNA, MBASusan Paschke, MSN, RN, BC, NEA-BC

Managing EditorCarol Ford

Editorial CoordinatorJoe Tonzelli

Layout DesignerBob Taylor

Education DirectorValerie Leek, MSN, RNC-NIC, CMSRN

Public Relations DirectorJanet D’Alesandro

Marketing DirectorTom Greene

Advertising CoordinatorHeidi Perret

Circulation ManagerRobert McIlvaine

New! FREE! Green!AAACN Offers Value-Added Benefits for All Attendees!

AAACN is pleased to partner with Digitell, Inc.to create our own 2009 Annual Conference onlinelibrary. As an attendee, you will receive unlim-ited free access to all approved educationsessions for one full year! That means you willnow be able to access those sessions you weren’table to attend – free! You can also invite two col-leagues to access the conference online – alsofree!

The online library will include all approved ses-sions from the conference (including live audio andpresentation slides). Attendees will receive a confer-ence code and can begin accessing content just 14days after the conference. Access includes multime-dia streaming and downloading.

And there’s more. Being socially responsiblefor our environment, all written presentation mate-rials will be available online two weeks prior to theconvention. You will no longer need to carry aroundthat heavy, bulky program book, and conferencematerials will be available for a period of one year.

If you want to bring any presentation materialswith you to the conference for the sessions you will

attend, you may download them from the Web site.You will receive a small booklet on site for note taking.

And there’s even more. Our paperless con-ference will provide you the opportunity of com-pleting your session evaluations online, either dur-ing or within one month after the conference. Onceyou complete your evaluation online, you can printyour contact hour certificate immediately.You’ll never have to choose between concur-rent sessions again!

Contact hours may be obtained for additionalsessions and by two of your colleagues for an addi-tional fee.

More information about accessing this excitingopportunity will be available on the AAACN Website at the conference. Sessions will be available forpurchase online after the conference for thoseunable to attend.

AAACN’s 2009 Annual Conference Online LibraryExperience the Entire Conference

Like Never Before!

There Is A Hole in the Bucket —Nursing Retention Strategies Used In a Large Canadian Call Center

By reading this article and completing this evaluation, you will earn 1.4 contact hours of continuing nursing education

Name: ____________________________________________ AAACN Membership number: ________________

Address: ___________________________________________________________________________________

City: _______________________________ State: ________________ Zip: _____________________________

Daytime phone: _______________________________________E-mail: ________________________________

Contact Hour Payment: ■■ Visa ■■ Mastercard ■■ AMEX card # ________________________ Exp: _________

Name as it appears on credit card (please print): ____________________________________________________

Evaluation Form Instructions1. To receive continuing nursing education credit for individual study after reading this article in this publication, com-

pletely answer all questions and mail the form with payment of $15 members/$20 non-members to AAACN, P.O. Box 56, Pitman, NJ 08071-0056. When using a credit card, you may FAX the form to 856-589-7463 or sendelectronically to ambp401@ajj.com.

2. Evaluation forms must be received by August 31, 2010. If you submit this form, a certificate for 1.4 contact hourswill be sent to you.

ObjectivesThe purpose of this continuing nursing education article is to increase the awareness of nursing retention strategies innurses and other health care providers.

If you applied what you have learned from this activity into your practice, what would be different?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Strongly StronglyEvaluation disagree agree1. By completing this activity, I was able to meet the following objectives:

a. Define “clinical engagement” and how it relates to nurse retention. . . . . . . . . .1 2 3 4 5b. Explain the benefits of communication in the workplace. . . . . . . . . . . . . . . . . .1 2 3 4 5c. Discuss the ways nurse managers can lead their staff

and ensure a positive perception. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 2 3 4 52. The content was current and relevant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 2 3 4 53. The objectives could be achieved using the content provided. . . . . . . . . . . . . .1 2 3 4 54. This was an effective method to learn this content. . . . . . . . . . . . . . . . . . . . . . .1 2 3 4 55. I am more confident in my abilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 2 3 4 5

since completing this material.6. The material was (check one) ___new ___review for me

Time required to complete the reading assignment: _______ minutes

I verify that I have completed this activity: __________________________________ _____________________Signature Date

This educational activity has been co-provided by AAACN and Anthony J. Jannetti, Inc.

Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses’Credentialing Center’s Commission on Accreditation (ANCC-COA).

AAACN is a provider approved by the California Board of Registered Nurses, provider number CEP 5336. Licensesin the state of CA must retain this certificate for four years after the CNE activity is completed.

American Academy of Ambulatory Care NursingEast Holly Avenue Box 56 • Pitman, NJ 08071-0056 • 856-256-2350 • 800-AMB-NURS • Fax 856-589-7463

E-mail: aaacn@ajj.com • Web site: www.aaacn.org

AMBJ804

ANSWER/EVALUATION FORMJ/A 2008 Viewpoint

CONTINUING NURSING EDUCATION ACTIVITY