The role of the equine ambulatory nurse is a new concept, recently in discussion across the equine veterinary profession, that sees equine nurses step up to use their skills in a new area. The overall aim is to offer a better team approach to patient management and encourage nurses to assist in the management of cases outside of the clinic (Figure 1), as well as taking on some of the tasks normally allocated to the veterinary surgeon, when not in the clinic.
For a while, the equine nursing role was somewhat behind that of our colleagues in small animal practice, with the absence of nurse-led consults, schedule three procedures, nurse clinics and district nursing. With the equine veterinary profession currently short of vets (Grieve, 2022), now seems like the perfect time to showcase equine nurses' skillset.
What is ambulatory nursing?
Ambulatory or outpatient care makes up a large proportion of equine work. Ambulatory vet and ambulatory nurse roles should not be confused, although the two are designed to work alongside one another. These roles are not intended to replace the role of the veterinary surgeon, but instead to support it and provide additional services and support that our vets do not always have the time or the training for.
Let's start with the legalities
To abide by schedule three of the Veterinary Surgeons Act 1966, registered veterinary nurses (RVN) undertaking this work must be employed by a veterinary practice and act under the direction of a vet (Rippingale, 2019). For this opportunity to work, veterinary nurses must stay within the Royal College of Veterinary Surgeons (RCVS) code of conduct, and must know and accept their limitations.
This means the new proposed role of ambulatory nurse is not intended for nurses setting up and working as an individual providing a standalone service. The new concept seeks to use the strengths and skills of the whole veterinary team, which contributes to improving patient care and helping with work–life balance by lessening the workload of vets.
Same role, new environment
Stepping out of the clinic and into a solo working environment can appear daunting, especially when veterinary nurses normally have a team to support them should they need assistance in the clinic. It should not be forgotten that there are some risks attached to the roles that equine nurses carry out, such as administering an intravenous injections. However, the skills and knowledge remain the same and nurses that have demonstrated these skills in a clinic environment should be encouraged to take these out to the yards. Ideally, additional training in consulting, client management and dealing with an adverse event should be provided before first visits to the yard; this can be through either in house or via external continuing professional development (CPD) sites. It is also advisable that a recap of the code of conduct and schedule three should be documented.
Being able to solely manage a consultation with a client in an external environment brings new challenges; it is therefore important that we choose the right nurses for this role.
What makes a good equine ambulatory nurse?
Organised, with good time keeping
Professional and confidential
A good communicator
A good listener
Confident in the role and the equipment
Able to deal with a variety of situations
Confident to work without the immediate backup of the clinic team
Be able to work around client's set ups without being judgmental
Able to stand by the RCVS code of conduct and not be persuaded to break the rules
Know when to refer back the veterinary surgeon.
When looking to implement ambulatory nursing into the clinic team, it is crucial that nurses are steered and supported towards roles that are going to encourage their professional development and interests, as there is not one role that fits all. There are other equally important areas for nurses to ‘specialise’ in around the clinic, such as intensive care and diagnostic imaging (Hartpury University, 2022). Nurses also pay a huge role in patient care, infection control and veterinary support at the clinic,. It is important to avoid staff shortages to ensure standards can be maintained if nurses are out on the road.
Before introducing ambulatory nurses into any team, everyone needs to be clear on the tasks that can be undertaken. This should be clearly documented and communicated across the whole team, including the administration staff or anyone responsible for making appointments. In the author's own clinic, ambulatory nursing is carried out on a referral basis – as in, the case vet will refer the case for the nurse to carry on with some aspects of care, then a plan is formulated and monitored. This has been a good starting point for implementing the role as it encourages teamwork, communication and support between the nurse and vet.
What can an ambulatory nurse do?
Bandage changes and wound management (Figure 1)
Blood samples (Figure 2)
X-rays
Demonstrate how to use equipment, such as inhalers (Figure 3)
Administer medication
Postoperative checks
Stitch and staple removal
Weight management, condition scoring
Advice
Biosecurity assistance
Home care, rehabilitation and management of cases following clinic discharge
Assist the veterinary surgeon with a variety of procedures.
What can't an ambulatory nurse do?
Make a diagnosis
Administer medication to an animal that is not under the care of their practice
Administer sedation to effect without the dose and approval from the veterinary surgeon
Administer a ‘top up’ dose without approval from a veterinary surgeon
Make or change decisions on case management with consulting the case vet
Comment on acquired radiographs other than their diagnostic quality.
Getting started
If ambulatory nursing is an area that sounds appealing and beneficial to your practice, taking steps to progressively implement the role into the team will have better long-term prospects for a better outcome.
An initial discussion within the clinical team on if and how this role can work is a good start. The author has found that some vets do not support the importance of this role, solely because they do not understand it. Therefore an open discussion should lead to a understanding of what this role is trying to achieve, the benefits and of course, any potential negatives. The whole team should be aware of the limitations of the role and a protocol should be drawn up. As previously mentioned, training should be provided from the clinical team, with more CPD for this area hopefully being provided in the future.
Building up client-facing skills
In many practices, nurses are already active in assisting vets on visits, with for example radiography, castrations, gastroscopy and endoscopy where a second pair of hands is required. Nurses that have not previously assisted on ambulatory calls should have some exposure to this to help develop further client skills and understand the challenges of working outside of the clinic.
Equine nurse clinics run in practice, such as weight management, are not as common as in small animal practice, although now there is more interest in this area. This again is a good way to introduce a nurse-led consult that still offers some support of the team if needed. Weight clinics, with mobile scales, can also progress into the ambulatory role and again offer a great starting point.
It is important to remember that nurses are already in client-facing, consulting roles in areas such as admissions and discharges. If these are not being done by nurses in the clinic at present, again this can be a good starting point to start obtaining directed responsibility from the case vet. This can also be carried out by completing a nursing care plan on admit with the client, and obtaining histories on behalf of the case vet, for example a lameness work up. All of the above will build confidence, communication skills and recognition from the client
Getting the clients on board.
For the role to work, the support of clients is needed. This should not be obtained by offering a nurse visit as a cheaper option. Instead, promoting the role and educating clients on its importance in the all-round care of the patient is key. Social media, practice websites and client evenings can all help with this, as can keeping patient continuity with allocating a nurse to a patient from the start for cases such as surgery and intensive care, enabling relationship building.
Vets actively referring cases to the nurse, and doing this openly with the clients, shows a level of trust and responsibility that also gives the client confidence in the new situation. Box 1 illustrates how the role of the ambulatory nurse can work in practice.
Box 1.An example of a team approach to optimal patient careToby, a 14-year-old Piebald cob used for hacking and leisure, presented to the clinic for a lameness investigation following poor performance. On arrival, a history was obtained by the RVN, which included a clinical examination and note taking; this information was relayed to the treating vet, who had just finished his previous case.Together, the treating vet and RVN carried out a lameness work up to establish the problem and plan of surgery was put in place.Before surgery, the treating veterinarian wanted to check Toby's current adrenocorticotropic hormone levels for pars pituitary intermedia dysfunction and the RVN was tasked to go to Toby's yard, where he was more settled and relaxed, to obtain the sample.On admission for surgery, the RVN completed an entrance nursing care plan with the owner during the admission. Following initial communication from the surgeon postoperatively, the RVN maintained the daily updates.The RVN and the surgeon jointly carried out the discharge, with the RVN discussing the proposed home care plan.The RVN visited Toby on several occasions on behalf of the treating vet to complete his bandage changes. Toby needed sedating for his bandage change and the dose was agreed with the treating vet; while there, photos were taken of incisions and an update given to the treating vet. Advice on helping to make Toby's stable more enriching while he was on his box rest was given to the owner. The RVN showed some tips on how to administer Toby's non-steroidal anti-inflammatory drugs as the owner was struggling to do this. Toby's owner asked about the rehabilitation and about a plan for his shoeing; the RVN recognised that this was out of her remit and referred the case back to the veterinary surgeon for Toby's final visit to remove the sutures where this could be discussed, and a further plan made.
The future
Overall, this is an exciting opportunity for equine nurses working in practice and the benefits to the patients, team and the future of equine nursing is clear.
However, for this to work it is important to ensure that the whole team and the clients are on board and that there are clear boundaries and protocols to adhere too.
Giving nurses who have spent many years working within the clinic the opportunity to try something new, giving extra opportunities and responsibility is also a great way to improve work satisfaction and staff retention.
For those nurses who do not feel this particular role is for them, clinics need to ensure their nurses' careers are moved forward in their own personal areas of interest and supported.