The Tactical Nurse in Action
I talk with a lot of nurses in a lot of community health centers across the country and let’s face it, for a lot of RNs their current job role sucks. Often they are chained to a phone or in charge of back office “crisis resolution” when in fact, there are very few crises to deal with in ambulatory care…unless more walk in patients than we have slots for day after day after day constitutes a crisis. Nurses are wonderfully skilled and educated clinic staff who can range from support staff (e.g. vitals, referral making, prescription clarification) to providers (e.g. UA treatments, education, quick visits). However, the recent years of hiring and then placing RNs in jobs which are below their talents has led many ambitious nurses to seek a way out of on-the-floor clinical work and it’s a shame to watch. While it is certainly helpful to understand what a Tactical Nurse is from a conceptual standpoint, the full breadth of what this role entails can only be grasped by seeing a tactical nurse in action—by walking a mile in his or her shoes.
Coleman Associates has assisted a number of health centers in implementing the Tactical Nurse role successfully. One success story of note comes from a clinic in Mendocino County, California. This clinic first decided to integrate its nurses cautiously and strategically into teams during a Coleman Rapid DPI.
Creating the Ultimate Team Player
Their first tentative steps into tactical nursing began on a small scale when they had their RNs huddle with the same provider/MA/front desk team every shift. The RNs identified patients in the huddle that they, the RNs, could assist with during the day by performing medication reconciliation, setting the agenda for the visit, and providing education. As the nurses learned more about their team’s patients and their needs, their tactical role quickly expanded, and soon they were off and running.
It was crucial at the start that these particular nurses were competitive and patient focused. They immediately began to scrutinize processes that had been in place for years, including the no-show follow up process. In this clinic, like many Community Health Centers, unless patients were flagged by the provider, the front desk staff simply sent all no-shows a postcard informing them that they missed their appointment and suggesting they call to reschedule. The nurses quickly recognized that this system allowed patients to fall through the cracks. So the nurses began calling no-shows directly in order to get them to come in for another appointment; they did this by explaining the importance of the appointment as it related to each patient’s specific health needs.
Through implementing these and other small changes, the nurses soon began to function as case managers and tireless advocates of their team’s patients. One of the most tangible changes made by the tactical nurses in this clinic could be seen in their refusal to re-schedule patients unnecessarily. Instead they were creative and tenacious and didn’t turn any patients away, even if a clinician was unexpectedly absent–which is exactly what happened on the day that the clinic was to fully pilot the tactical nurse process.
The Real Test of Skills and Stamina
Since these nurses had learned to function as case managers, educators, and coordinators, they knew their patients well. On this day when they were to pilot a new process, the clinician was unexpectedly absent (leaving only one part-time MD on the team). Instead of rescheduling the provider’s patients the nurses took ownership of that clinician’s schedule. The nurses really kept their cool and they didn’t ask the front desk staff to start calling patients in order to reschedule. Instead they went to work as skilled members of this health care team. As each patient showed up, they explained the provider absence and gave the patient the choice of whether or not to reschedule or get a quick visit today. Patients were fine with a quick visit. They took each patient back to an exam room where they reviewed that patient’s history and medications, performed a focused nursing assessment on the patient, and set the agenda for the visit. Setting the agenda for these patient visits involved having an initial conversation to discern the patients’ needs for the visit. This was crucial in understanding the patients priorities and determining the necessity of a focused visit from a medical provider.
The nurses also provided patients with education and an explanation of treatment possibilities, including the most common diagnoses and side effects. They refilled medications according to set protocols and contacted specialists directly for follow-ups and referrals. When necessary, they found a clinician who was in-between patients. The nurse then presented the patient’s case in a 30-second report (which is part of what Coleman calls the “Coleman Team Dance” process), which was followed by the clinician seeing the patient for a quick, focused, well-planned educated 5ish-minute visit.
Of course, this entire process was initiated by giving the patient the first choice–the nurse greeted patients, explained why they weren’t seeing their provider today, and offered patients the option of having a nurse visit and possibly a focused quick visit with another health care provider. Every patient opted for the alternate provider and the 5-minute visit. As a result, every patient that a clinician saw became a billable provider visit. By employing tactical thinking, these nurses helped develop the most “productive” team.
And what was the end result of this skillful, coordinated effort? The team worked together like a well trained relay team, each filling his or her role and tagging each other to swiftly complement the previous team member’s performance in order to ensure the best patient centered care.
Nurses enhanced the team productivity and reach–but not by shortchanging the patient but rather by integrating the patients’ care into the team.
The first day they piloted this model, the part-time physician on the team saw 26 patients in 5 hours. He averaged 5 patients per hour (that comes out to 5.2 patients per hour) up from a baseline of 2.4 patients per hour. These were all billable encounters. Most importantly, 15 patients who would otherwise have been rescheduled were seen by a nurse, and when necessary a clinician. They received quality treatment and were scheduled for appropriate follow-up care. This is the optimal use of a tactical nurse.
And the patients weren’t the only winners of this race; the team members finished their charting and went home on time. This was in large part because the team helped share the work of charting..work that typically falls to the provider at the end of the session or day. This model proved so successful that the nurses on this team decided to continue to see patients in this manner whenever clinicians were out on vacation or extended leave.
Other appropriate uses of tactical nurses in this clinic included diabetic education and hypertension clinics led by the nurses one day each week. While one nurse led these education sessions, the other nurse assisted with patients on the floor, called scheduled patients, and began follow-up with established patients. This interdisciplinary approach to visits and education proved to be rewarding for everyone.
The tactical nurse approach ensures continuity of care between providers and teams while keeping the clinic from falling into chaos whenever there is an unexpected/last minute provider or team member absence and to have unexpected time off, and also maintains productivity goals for the team. The success of this model provides optimal access for patients, maximization of the nurse’s autonomy and skills, and flexibility of time, appointments, and services within the team.
As you can see every tactical nurse is a leader, manager, and follower. Like the winning relay team that relies on everyone’s active participation, tactical nursing requires:
- a high level of commitment,
- flexibility, and
- a keen eye for where the team is during the race.
Leading requires innovation and risk, managing requires an ability to persist in goal achievement, and following requires a desire to contribute productively to the team. Tactical nurses are risk-takers who effectively engage with a range of stakeholders in the health system, and who make every effort to accomplish the best possible outcomes for the clinic, the team, and the patients.
Written by Laura Spindola, RN