Surgery centers and others in ambulatory healthcare always try to find the best nursing staff. As the most experienced nurses retire over the next decade, improving the nursing hiring pipeline becomes a challenge.

“There are some strategies proposed, but they’re not implemented in a way to get to the outcome that’s needed,” says June Levine, MSN, BSN, RN, patient-centered medical home director at Southside Coalition of Community Health Centers in Los Angeles.

For instance, new nurses rarely learn about ambulatory care as it’s not part of most undergraduate nursing studies, she says.

“Many people are asking academic programs to include ambulatory care,” she says.

But the academic programs are focused on educating students to pass the RN boards, so they focus most on the topics that will be covered in the tests and on those subjects that are required for nurses to meet the changes in medicine and nursing, she adds. If nursing students are interested in ambulatory medicine, they could take an elective course, but most do not for several reasons.

“One problem that occurs is that a new RN has difficulty finding a job at a hospital, so she sees an ambulatory position open and thinks she could do it for a year,” Levine says. “Ambulatory care is not the traditional doctor’s office anymore, and they don’t understand the pace and issues.”

Therefore, any program designed to increase the number of new nurses who go into ambulatory nursing must address early exposure to ambulatory care in nursing schools. Developing an ambulatory nursing residency program is one possible solution. It might not be feasible for every ASC, but there are some smaller steps administrators could take to improve orientation and training of new nurses or training of experienced nurses who are new to ambulatory care, Levine says. Here are some of her suggestions:

Study existing nurse residency programs. The American Academy of Ambulatory Care Nursing (AAACN) offers an ambulatory nurse residency program.1 The program is designed to help nurses transition to ambulatory care, whether they are experienced nurses in other specialties or new RN graduates. The program can be customized for an ASC or other settings, and it includes a curriculum guideline, competency assessment, clinical rotation guidelines, checklists, templates, simulation guides, and preceptor and mentor tools.

“It’s comprehensive and has connectivity between all of the components new nurses have to do,” Levine says. “Curriculum is built around a nursing job’s specific specialty area.”

Take small steps toward building better orientation and competencies. When it’s not possible or pragmatic to engage in a full nursing residency program, ASCs could take some smaller steps. These would help with transition into a new specialty or transition into practice.

“Sometimes, you might start building toward a residency program because, ultimately, that’s what you need,” Levine says.

For instance, an ASC could start by training nurses from existing staff to be preceptors for new nurses.

“Traditionally, orientation is two weeks and they expect the new graduate or RN who comes in with experience in acute care, but no experience in ambulatory care, to need less education on the job,” Levine explains.

She also recommends ASCs use an existing residency program as a guideline for training new nurses. The program’s competency items also could be helpful to assess new staff during the orientation period.

Vary the orientation or residency program according to staff’s experience. While a new nurse graduate could benefit most from a full 12-month residency program, an experienced acute care nurse might perform well in a four- to six-month program, Levine offers.

“They will pick up things quicker and have stronger skills in assessment and follow-up,” she says.

The person in charge of the orientation or residency program must retain knowledge about all the competency areas and how to build in preceptor time, simulation time, and class lecture time to suit the needs of each practice area.

Adjust the program to an ASC’s specific needs. When an ASC adopts the AAACN or another residency program, it’s important to adjust areas to the surgery center’s specific needs.

“You will use the program’s roots, but substitute some of the specific details,” Levine advises. “For example, you wouldn’t necessarily have an in-depth lecture on diabetes care, but you would make sure the RN asks certain questions and checks on a patient’s history and recent labs before the patient goes into a same-day surgery.”


  1. American Academy of Ambulatory Care Nursing. Ambulatory Care Nurse Residency Program. Available at: Accessed Feb. 21, 2018.