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Nursing: Management Concept


Ambulatory care has often been offered at places of work, clinics, and the out patient centers of health care institutions. Some ambulatory care is offered in educational institutions. The logic behind offering health care in places where people habitually spend their time instead of obliging them to go to a different setting to receive their health care is that it leads to more effective utilization of health care resources. Some ambulatory care units depend to a great deal on the expertise of nurses whereas others rely on medical care and physician assistants. Ambulatory care is regarded as an alternative means of managing care and offering health services. Due to the skyrocketing costs of health care, “the health care industry has adopted a shift of patient care from in-hospital care to outpatient setting thus leading to an increase in ambulatory care settings,” (Jones & Beck, 1996, p. 67). Besides an increase in the number of patients, the nature of patients receiving health care is also changing, symbolizing more ill patients suffering from one or more chronic diseases. This tendency has created the necessity to hire additional nurses in the outpatient unit. One consequence of this tendency is the high movement of nurses from critical care to ambulatory care settings. While some expertise of the nurses can easily be transferred from acute to ambulatory care setting, the competencies required by acute care nurses and ambulatory care nurses are not similar. This paper will examine management concepts critical to an ambulatory care setting.

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You are a nurse practitioner who recently finished your NP program and passed the certification exam. You have accepted a position in a large family practice. There are 9 physicians in the practice some of whom at varying points of time are out of the office. You will be one of two nurse practitioners in the practice. The previous NP left because he had a conflict regarding his scope of practice. The second NP has been with the practice for ten years. You will not have a panel of patients of your own at this time. Your role is to manage the paraprofessional staff and to triage patients for those physicians who are not in the office on a particular day. You actually may see 5 walk-in and triage patients a day. From the list of 6 major concepts, apply and explain why those 6 management concepts will have the biggest impact in your making a strong professional transition into your new role.

Development of Management Concepts

Leadership/management theory

Leadership in ambulatory care setting, whether in a hospital unit or a non-hospital setting, guarantees a sustained collection of competent employees who ensure unrelenting, efficient organizational performance. In an ambulatory care setting, nursing succession planning may take place at different levels including the unit or organizational level. It can also take place within a specific service level, or at the management level. Such a process is also appropriate in maintaining leadership in professional nursing settings. Effective leadership in an ambulatory care setting creates numerous opportunities for the nurses and paraprofessionals working at different levels of the healthcare organization (Swan & Moye, 2009). To attain excellent outcomes in the ambulatory care setting, the nurse should institute an efficient and highly focused tactic that zeroes in on the entire organization’s excellence. Skilled and knowledgeable ambulatory care nurses should expand these leadership competencies with time, enhancing in superiority and parallel with the organization’s tactical plan and vision. The experienced nurses should also develop leadership competencies among the paraprofessionals working in the ambulatory setting besides the clinical competencies.

The fundamental focal point of leadership is to accurately project the strategic needs of the ambulatory care setting (Swan & Moye, 2009). The projecting procedure enables the organization to identify the skills that are already present within the organization, and the skills that are lacking or inadequate and that need to be employed or developed from within the organization. In ambulatory care setting, projection of the organization’s strategic needs goes together with the employment of new nurses and paraprofessionals as well as developing their talent through mentorship and guidance programs by the experienced professionals (Haas, 2009).

There are several methods of leadership that are applicable to the ambulatory care setting. The top-down leadership approach involves the top management coming up with decisions and communicating them to the employees. Such a strategy is most applicable in emergency and critical situations where there is no or limited time for negotiations. It should not be used in normal circumstances because it kills the morale of employees. The futuring strategy entails the external examination of the environment for inevitable modifications and responding by balancing the organizational expertise with ensuing needs. The rifle strategy entails solving particular problems as they occur. Problems and conflicts are inevitable in ambulatory care settings and the nurse needs to have effective problem-solving skills. The bottom-up strategy is pioneered by employees through making of decisions which are then communicated to the top management. This strategy has proven to be one of the most effective leadership strategies because it values the contributions made by employees which in turn increases their morale. One of the characteristics of health care organizations with good performance is their possession of leadership competencies. This requires “not only getting the right people on the bus but also getting the right people in the right seats” (Collins, 2001, p. 27). This entails hiring the proper skills and placing them in the appropriate positions within the organization. In addition, it entails helping and supporting people in building their expertise and skills.

As a nurse practitioner in the scenario, the leadership concept is important to me for a number of reasons. First, possession of the leadership competencies will enable me to steer the ambulatory care setting towards the achievement of its goals and mission. This can be achieved through matching the needs of the care setting with the appropriate and adequate expertise of the paraprofessionals, other nurses, and physicians. It would require meeting the needs of the patients with the available resources. I ought to identify whether there are adequate paraprofessionals, nurses, and physicians in the ambulatory care setting as compared to the influx of patients. Are the patients receiving adequate and quality care? If this is not the case, what are the factors hindering the access of patients to quality care? If the factors are lack of medical staff needed fro the smooth running of the setting and scarcity of resources, then it would be my responsibility to communicate this situation to the management of the organization so that appropriate actions are taken to address the problems. Leadership competencies would also enable me to handle conflicts and solve problems in a professional manner. Conflicts are inevitable and may arise between the clients and the healthcare providers, or among the healthcare professionals.

Decision Making/Critical Thinking

Discussion in nursing rotates around the issues of problem solving, decision making, critical thinking, and critical analysis. Decision making is a procedure that entails measures that are undertaken in the solving of problems within an organization or setting. Critical thinking on the other hand is the ability built in searching for different solutions to problems and taking on a questioning strategy. Critical thinking in ambulatory nursing entails intellectual skills and utilizes rational logic to make decisions in difficult circumstances. Jones and Beck (1996) argue that “problems confronting nurses today emphasize the need for more than just rote memory, knowledge of skills, and the ability to follow directions,” (p. 4). Nurses need to produce huge volumes of information, figure out difficult clinical situations, and make vital decisions as growing patient care challenges come up. Critical thinking also entails an active and purposeful thinking, a process of examining the options available before making a final decision, and giving the justifications for the decisions made in a transparent and flexible manner as well as adopting an inquisitive approach to dealing with issues.

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Nurses in ambulatory care settings are dedicated to offering safe, effective and quality care that is patient-centered. Nurses in ambulatory care settings that that build their critical thinking skills are able to empathize with their patients and analyze the opinions of those they deal with including physicians, paraprofessionals, fellow nurses, patients and their families/friends. Critical thinking is facilitated by critical analysis, a tool that entails addressing several questions in each situation. These questions include: What is the fundamental concern? What are the inherent suppositions? Is there convincing proof? Are the inferences satisfactory? Critical thinking and analysis lead to effective decision making which is vital to the field of nursing and for addressing problems that arise in the allocation of resources and management of nursing practice (Marquis & Huston, 2008). Critical thinking and analysis facilitate the making of sound decisions in the ambulatory care setting.

Critical thinking and decision making are important to me as a nurse practitioner in the scenario. I have to make decisions regarding the actions that need to be taken by the paraprofessionals and the other nurse. Such actions may be needed by a group of patients having comparable health, demographic and psychosocial characteristics. Critical thinking and decision making abilities would also help me to assist patients in making decisions that concern their health. Critical thinking and decision making are also important in the setting because they are linked with enhanced clinical expertise. Utilizing critical thinking, I would be able to create and implement a plan of nursing care necessitates that take into consideration the human elements that are likely to affect the plan. It is also important to me because my practice forces me to frequently associate with patients, families and other health care providers in the process of delivering suitable, customized nursing care. Thus, I need to reflect on elements of the nurse-patient association.

The fundamental elements of critical thinking behavior include holding back judgment and openness to alternatives and justifications given by each patient even in similar situations. The unique elements brought by patients and healthcare professionals to the ambulatory care setting need to be regarded, evaluated, assessed, and analyzed. Analysis of the information then enables nurses to focus on the issues that are most appropriate and most vital to each circumstance (Jones & Beck, 1996). Most importantly, critical thinking would enable me to make sound decisions when faced with critical situations. For instance, if a critically injured patient is brought to the care setting but there is no physician in the office, critical thinking would enable me to make decisions and take actions that serve the best interest of the patient. In such a situation, I can make use of telephone triage to ensure that the patient receives fundamental care before any physician is able to see him/her in person.

Changing Roles and the Organization

Nurses have more chances of portraying their worth in the managed care setting. Nevertheless, in this era of dynamic transformations in the healthcare environment, the role of nurses has become more unclear. Management of health care organizations lacks an apparent means through which it can position nurses in the primary care units. Nursing refers to “the diagnosis and treatment of human responses to actual and potential problems,” (Ritcher & Felix, 1999, p. 226). This definition offers a vital connection to the recognition of the manner in which the skills of nurses fit in with the up-and-coming health care strategies. Nurses possess a broad variety of expertise which enables them to take on different responsibilities within the health care organization (Ritcher & Felix, 1999). Thus, gaining insight into the changing role of nurses requires knowledge about the main influences of care management. The health care industry has shown that these factors can work to both reduce costs and improve quality. Nurses play central roles in many of these solutions through the management/coordination of patients and direct care (Marquis & Huston, 2008).

As a nurse practitioner in the ambulatory care setting, changing roles of nurses are important to me and my practice. My fundamental role is to provide primary care to patients. However, my roles go beyond that. I also have the role of being an advocate for patients by ensuring that they receive adequate and quality care. My roles would also entail supervising the paraprofessionals to ensure that they perform their duties well and that they have access to all the required resources. My roles also extend to leadership. As a nurse practitioner in the ambulatory care setting, I have the responsibility of ensuring the smooth running of the center and making the management informed of any issues or decisions that take place. The concept of changing roles of nurses is indeed critical to my practice. In order to perform these roles efficiently, I would have to remain up-to-date with all that is going on in the nursing field and in the healthcare industry as a whole. This implies that I would be forced to acquire more skills and knowledge to enhance my professionalism. This can be achieved through taking additional classes, attending workshops, conferences and seminars, as well as training programs.

Organizational, Group and Interpersonal communication

Communication occurs at different levels and this depends on the expertise area of which nurses would need to be competent in them. The intrapersonal level of communication is normally the most basic. The organizational, interpersonal and group levels form other communication levels. The process of intrapersonal communication takes place within individuals and involves ongoing dialogue of thoughts that are helpful in decisions of future plans, handling of internal conflicts and evaluation of relationships with others and personal behavior. Interpersonal communication is the communication that takes place between two people. It can also occur through means such as a telephone or face to face. Indeed it is at the heart of the practice of nursing. Group communication takes place between three or more people in the process of interacting with one another. Organizational communication is the system involved in dissemination and transfer of information within an organization, for example, the communication between hospital management personnel, staff and medical officers. This communication level often involves the previous levels of communication (Marquis & Huston, 2008).

Communication between the nurse and the client is the most common in settings of health care with interpersonal communication normally between two people being significant. Interpersonal communication in this situation differs in purpose from communication in social situations. Client-nurse communication aims at establishing a therapeutic relationship for the benefit of the client, even in situations when the contact is brief. The needs of the other person are given emphasis over personal needs in any therapeutic relationship. Therapeutic communication is characterized by limitation of time, focus on the client and purposefulness. The process involves the nurse’s knowledge and response to the client as a unique person, and the client’s ability to trust the nurse. The communication between the nurse and client during times of the most intimate nursing care or emotional significance is based on comfort in a therapeutical relationship. The sensitivity of the nurse, feelings and needs of the client is continuous throughout the relationship. The nurse’s assistance to clients in identifying, adapting to or resolving their health problems reveal that the therapeutic relationship is based on purpose (Funnell, Koutoukidis & Lawrence, 2009).

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Communication in the ambulatory care setting has a significant impact on my practice as a nurse practitioner. Effective communication skills would enable me to interact at various levels and in different situations with people. The relationship qualities between people determine the effectiveness of communication whose importance applies to all areas of life. It is necessary for me to effectively communicate with clients therapeutically and effectively with all those involved in the health care environment. Communication, particularly interpersonal communication, also affects the way clients experience illness. Although I am expected to apply skills in my service to clients, it is important for me to promote trust feelings in the clients by engaging them in helpful and supportive communication. I can demonstrate effective communication skills my ability to: listen to others attentively, assist clients in communicating their needs, and communicate information to clients, their relatives and the healthcare professionals. This would help to clearly relay accurate information to healthcare professionals so that they are able to provide quality and adequate care to patients. Effective communication would also enable me to empathically respond to feelings experienced by patients and their relatives (Funnell et al., 2009).

Conflict Management

Conflict in ambulatory care setting is inevitable due to the complex interactions between health care professionals, patients and families. All conflicts are unique although the existence of common elements can be identified. A good conflict management framework identifies strategies used in uncovering the triggering event of the conflict; historical content of that conflict; the interdependence levels among the participants; and the resources, issues, goals and solutions previously considered. Communication behaviors of the people involved party and their perceptions towards these behaviors are the underlying factors of the elements of conflicts. The relationship between the participants of conflict and the meanings they ascribe to their relationships are very important. In addition to this, culture, socio-economic status and gender have great influences on perceptions. Socialization on the roles and responsibilities based on professionalism of various disciplines in healthcare normally makes contributions to conflicts that are significant. For example, the socialization of nurses through state nurse practice acts and professional care standards and practice may influence them in failing to provide care to patients due to feelings of incompetence. Conflict normally arises when the top management contends that minimal training is the only one necessary with assumptions of similarity in the competencies for patient care (Sportsman, 2005).

Process goals normally involve the determination of the communication processes that will be most helpful in conflict resolution. Healthcare organizations have many communication systems both formal and informal, and conflict can escalate in situations where the parties have differences in expectations about systems used for resolving the conflict. For example, if the issue regarding competence for the nursing staff is not addressed, concerns that there is interference with practice by nonclinical administrators could escalate the conflict. An effective conflict management framework recommends that the impact of power on the conflict be assessed. All conflicts are based on aims to protect the self-esteem of the participants or change the inequities in power perceived. This is because most participants believe that the other person or persons have the higher power in the situation. Therefore, the examination of the influence of power is crucial in understanding the conflict. For example, the power base of supporters of the expansion of a day surgery is increased through their ability in generating more revenue based on service to additional patients. However, this group may have other power sources such as strength of relationships with administrators, skills in the communication of the needs of patients or the equalization of the power equation by the board members (Sportsman, 2005).

Conflict management in the ambulatory care setting has a significant influence on my practice as a nurse practitioner. This is because the process of developing a clear picture of the events that trigger conflicts and the historical context surrounding it gives allowance for the identification of inherent issues in the conflict. In managing conflicts, I can categorize issues in accordance with the interests that cannot be agreed upon, values and facts. For example, when issues based on interest are involved, disagreement over who will get what in scarce resources distribution normally surface. The identification of issues leads to an understanding of the goals hoped to be achieved by each participant. Participants to the conflict normally view their goals as incompatible to their opponent’s desires. Thus it is imperative for me to manage the conflict in a manner that will be perceived as fair by all the parties involved in the conflict (Marquis & Huston, 2008). Conflict management is also important for the smooth running of the ambulatory care setting.

Quality Management

In today’s health care setting, the quality of care is an important element in today’s health care setting including an ambulatory care unit. Quality management can be achieved through continuous quality improvement (CQI). The main goal of the quality improvement program is to enhance the quality of care provided to patients by increasing patients’ and staff satisfaction. The CQI efforts of a healthcare organization are guided by the leadership commitment of the organization.

Leadership commitment

The understanding and active dedication of the system’s leadership will provide the platform upon which successful execution of the CQI will be realized. The leaders should therefore share the same vision, support the same principles and motivate those they lead to do the same. The leaders should take the full responsibility of supervising the quality improvement efforts (Gothard & Wixson, 1994). In order to ensure a smooth running of the QI program, a clinical quality improvement committee (CQIC) needs to be formed. This committee needs to report directly to the medical executive committee (MEC). The CQIC in the ambulatory care setting should be made up of physicians, nurses, paraprofessionals and other medical staff. The responsibilities of the CQIC are: to recommend and execute corrective action where needed; to report the results of the QI to the MEC on a regular basis; to determine the variables of quality that need to be measured; to create valid pointers for assessing the quality of care provided, as well as the challenges and opportunities that exist for improving the quality of care; to take part in decision-making processes; and to assess the effectiveness of the measures taken by the healthcare system. The smooth running of the CQIC will be enhanced through various quality improvement tools such as plan-do-check-act cycle, balanced scorecard (BSC), and brainstorming.

Focus on process improvement: the plan-do-check-act cycle

In order to successfully undertake the CQI program, the ambulatory care setting needs to adopt the plan-do-check-act (PDCA) cycle. The PDCA cycle is a tool that will help the healthcare organization to identify the processes and measure the outcomes for improvement, assess the approach for change, evaluate the data collected, and implement the QI strategy (Motwani, Klein & Navitskas, 1999). Based on the PDCA, the unit can design new products, introduce new services, and change some functions or processes in accordance with the program’s vision and mission as well as the needs and anticipations of clients and employees.

Balanced Scorecard (BSC)

A balanced scorecard is a quality improvement tool that focuses on four major elements of the organization: customer, business process, learning and financial. The customer element addresses the needs of the patients particularly as far as their safety and the quality of care they receive. In this ambulatory care setting, the opinions of the patients about the quality of care they receive from the medical staff will be collected. The data will help the organization to identify the areas of care provision that need improvement. The business process addresses the areas in which the organization must excel at. In this setting, the organization is interested in improving the quality of care of patients by addressing the human resources challenges it currently faces such as inadequate medical staff. The learning element addresses the activities and programs the organization will undertake to ensure continued improvement. Lastly, the financial element addresses the resources available or lacking in the organization (Motwani et al. 1999).

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Brainstorming is one of the tools used in quality improvement. It entails searching for ideas and implementing the most appropriate ones. In this particular ambulatory care setting, the CQIC will hold several regular meetings to discuss the problems currently facing the organization and to search for the solutions. Brainstorming will require total cooperation from all members of the quality improvement team. Generation of ideas can be done in an organized and structured manner in which every member is given a turn to give his/her opinion. This is due to differences in personality which may prevent some members to share their views even if they are of great importance. It is important for members of the CQIC to realize that every idea is valuable and can go a long way in solving the current problems facing the organization. It is also important for feedback to be given to the members of the team (Hoskins, Sayger & Westman, 2002).

Quality management is important to me as a nurse practitioner. This is because patients today are more empowered and demand higher quality of care. Thus, the quality of care provided by the paraprofessionals, nurses and physicians affects the perceptions of the patients towards the ambulatory care setting. It also affects the interactions between the patients and healthcare providers. As a nurse practitioner, I can help to improve the overall image and satisfaction of patients by helping to implement continuous quality improvement measures.


The ambulatory care setting in the scenario is capable of running smoothly as long as the management concepts discussed above are implemented effectively. The nurse needs to implement effective management and leadership strategies that entail identifying and building the talents of the professionals as well as ensuring the optimum allocation of resources. Of great significance to the ambulatory care setting are also critical thinking and decision making abilities, effective conflict management strategies to solve the conflicts that inevitably arise among the partners involved, quality management to improve the quality of care provided to patients, and communication strategies to enhance the care provided and the relationships among the health care providers, patients and families.

Reference List

Collins, J. (2001). Good to great. New York: Collins Business.

Funnell, R., Koutoukidis, G., & Lawrence, K. (2009). Tabbner’s Nursing Care: Theory and Practice. Chatswood, NSW: Elsevier Australia.

Gothard, L., & Wixson, N. (1994). Charting a Course for Continuous Quality Improvement. Risk Management, 41(1): 27-33.

Haas, A. (2009). Priming the pipeline: Creating aspirations for new graduate nurses to enter ambulatory care nursing roles. Nursing Economics, 27(1), 58-60.

Hoskins, E., Sayger, S., & Westman, J. (2002). Quality improvement in patient distribution at a major university student health centre. Journal of American College Health, 50, 303-308.

Jones, P., & Beck, S. (1996). Decision making in nursing. Albany, NY: Delmar Publishers.

Marquis, B., & Huston, C. (2008). Leadership Roles and Management Functions in Nursing. Philadelphia: Lippincott.

Motwani, J., Klein, D., & Navitskas, S. (1999). Striving towards continuous quality improvement: A case study of Saint Mary’s Hospital. Health Care Manager, 18(2): 33-40.

Ritcher, P., & Felix, K. (1999). Adding value by expanding RN roles in ambulatory care. Nursing Economics, 17(4), 225-228.

Sportsman, S. (2005). Build a framework for conflict assessment. Nursing Management, 36(4), 32-40.

Swan, B., & Moye, J. (2009). Growing ambulatory care nurse leaders: Building talent from the primed pipeline. Nursing Economics, 27(4), 251-254.

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