The U.S. health care system needs to be fundamentally redesigned because the current model of care is not meeting the needs of the population for primary care. Several factors are negatively affecting the primary care workforce, such as a decrease in primary care providers, an increase in the aging population with limited health insurance, and a decrease in timely appointments for patients (Ganguli et al., 2019; Vanhook et al., 2018). Moreover, four of ten members of the aging population have multiple chronic conditions. These conditions can pose a burden not only to this population, but also to the health care system (Buttorff et al., 2017). Access to care, continuity of care, comprehensiveness of care, and coordination of care are functions that are necessary for optimal primary care processes and health outcomes (Ellner & Phillips, 2017). Research has emphasized that primary care redesign and the implementation of team-based care can increase access and positively affect health outcomes (Josiah Macy Jr. Foundation, 2016). RNs practicing in an expanded role are uniquely positioned to address the primary care crisis, and they add value to team-based care. For example, a recent study demonstrated that in 30 innovative primary care practices, RNs in expanded roles—including, but not limited to, providing (a) face-to-face patient care, (b) transition of care between acute and primary care, (c) care during routine visits for preventative care, (d) acute and chronic care, and (e) specialized care within the primary care clinic for prenatal or warfarin management—were regarded as value-added services (Flinter et al., 2017). Moreover, the primary care providers reported that using RNs in a team-based model had a positive influence on their practice (Flinter et al., 2017).
Following the Institute of Medicine's landmark report The Future of Nursing (2010) and a more recent position paper by the American Academy of Ambulatory Care Nursing (2017) on the role of the RN, there has been growing support for using RNs' full scope of practice in primary care. The Josiah Macy Jr. Foundation (2016) published recommendations from the Macy Foundation Conference for preparing RNs to undertake enhanced roles in primary care settings. The American Academy of Nursing Primary Care Expert Panel has underscored the need to address the primary care crisis, asserting that the solution is not to increase primary care providers but to optimize the primary care team by including RNs prepared with a Bachelor of Science in Nursing (BSN) degree to deliver primary care (Vanhook et al., 2018).
RNs possess the requisite knowledge and skills needed to work as an integral part of the primary care team (Josiah Macy Jr. Foundation, 2016); however, limited data exist on the academic and clinical preparation of RNs for practicing these skills in the outpatient or primary care setting. Despite recommendations to expand the role of RNs in primary care settings (Smolowitz et al., 2015), most traditional prelicensure nursing programs do not prepare students to practice in primary care or ambulatory settings (Bodenheimer et al., 2015).
Wojnar and Whelan (2017) surveyed 1,409 schools and/or colleges in the United States. Of the 1,409 surveyed schools and/or colleges, only 529 responded. Most (n = 302) of those that responded were from BSN and master's nursing programs. Of the 302 BSN and master's nursing program responses, the majority (n = 232, 76.8%) reported that limited primary care content was included in their curriculum. Respondents from Associate's in Nursing degree programs (n = 179) indicated that some primary care content was included in theory and clinical practice courses, but to a limited degree.
Recent literature has demonstrated that nurses prepared at the BSN level can work effectively in teams. In the Robert Wood Johnson Primary Care Team: Learning from Effective Ambulatory Practices program, BSN-prepared RNs were successful in providing preventive and chronic care management (Flinter et al., 2017). Smolowitz et al. (2015) interviewed participants from 16 primary care practices across the United States who all identified as having sustainable models for improved patient outcomes using a team-based approach in which RNs practiced to the full extent of their education and training. The authors categorized RN activities according to context:
Episodic and preventive care
Chronic disease management
Within these three contexts, the RNs were responsible for (a) delegated care for episodic illness management, (b) telephone triage, (c) medication reconciliation, (d) health coaching, (e) assessment and documentation, (f) case management on chronic illness, (g) hospital transition management, (h) practice management and staff supervision, and (i) quality improvement (Somolowitz et al., 2015). The primary care practices reported better patient quality outcomes and provider satisfaction using RNs in their team-based approach to care. For example, having RNs allows physicians more time to see more complex patients, which, in turn, increases patient volume and decreases emergency department visits (Smolowitz et al., 2015). In addition to decreasing emergency department visits, hospital admissions, or readmissions, RNs in ambulatory care have led to improved patient comes in the areas of patient satisfaction, communication, patient self-care, and quality of life (Allen, 2016).
The literature provides evidence of the need for primary care redesign, team-based care, and discussion of how RNs can play an integral role in the primary care setting. However, there is limited literature that explores educational programs to prepare RNs to use their skills and knowledge in team-based practice in the primary care setting. The purpose of this article is to describe educational programs for RNs hired to work in an expanded role in a primary care setting.
The Role of RNs Transitioning Into Primary Care
The RNs role transition from an acute inpatient to a primary care setting can be both exciting and challenging, requiring a role change for practicing as part of a team (Josiah Macy Jr. Foundation, 2016). Two primary care clinics within our institution restructured their care delivery model from a traditional patient–provider visit to a patient–team visit that included an RN in each team. The newly hired RNs' responsibilities included (a) disease management, (b) assessment of disease state and utilization, (c) care plan development and facilitation, (d) transition of care, and (e) referrals. Additionally, RNs in this expanded role were responsible for communicating and coordinating with members of the team regularly to reduce gaps in care or fragmented care. In response to the need to create capacity in the health care system and to increase access to primary care, the RNs function as an integral part of the team was focused on achieving optimal clinical outcomes through a seamless model of access and care.
Approach to Learning Needs Assessment
For the purposes of this project, the author, a nursing school faculty member with approximately 18 years of expertise in primary care, formed a partnership comprising the health care organization's administrative leadership (Chief Nursing Officer and Director of Nursing). The author met with the administrative leadership to explore their organization's needs and identify existing gaps for their newly hired RNs and future RNs preparing to assume expanded roles in the targeted primary care clinics.
Other discussion included the RN's role functioning as an integral part of an interdisciplinary team, identifying learning content, method of delivery, and strategies for delivery to the organization's RNs. During several meetings with the administrative leadership and some of their established RNs working in expanded roles, topics were identified related to enhancing the newly hired RNs' orientation process as they transition into the primary care practice. The author used some of the key domains identified in published documents, such as preventive care and chronic illness comanagement (Bodenheimer et al., 2015; Smolowitz et al., 2015), as well as the learning needs specified by the RNs who participated in the meetings to design learning content related to face-to-face care delivery for the organization's nurses.
Some of the learning needs included introduction to primary care setting and concepts, chronic care management in the primary care setting, annual wellness visits, and cancer screenings. These meetings provided the basis of developing the learning content for the newly hired nurses.
The program was designed to enhance the orientation of the newly hired RNs in the primary care and ambulatory settings. The author outlined the topics and developed learning objectives. The overall learning objectives for the newly hired RNs were to: (a) provide an overview of the principles of primary care into practice, including models of care; (b) discuss the role of the RNs as leaders in primary care; and (c) discuss the role of the RN as a team member providing team-based and patient-centered care, health promotion and disease prevention, and patient education in the primary care setting. The role of the RN as a team member was threaded throughout the content. Learning topic titles for the content included Introduction to Primary Care, Health Maintenance, Patient Education in Diabetes Management, Adults with Hypertension, Motivational Interviewing, and others (Table 1). The content was delivered face-to-face over two sessions; the first was a 4-hour session and the second was a 2-hour session. In addition to lectures and discussion, the author presented vignettes regarding health maintenance, management of chronic conditions, and highlighted the importance of motivational interviewing in each session. Vignettes have the potential to increase nursing knowledge through learners' participation in problem solving and decision making during a clinical scenario (Keen et al., 2017). The vignettes were based on clinical scenarios, which allowed for rich discussions of each scenario as a problem-based learning strategy.
RNS in Primary Care
The author created a site in the university's learning management system, an electronic software application used for the delivery of educational courses, into which content was uploaded and learning activities were categorized into modules according to topics. The multidimensional modules were created to enhance learning as they contained multiple learning resources, such as voice recorder lectures, video links, and readings. This delivery format allowed the organization's nurses to review the content at a time convenient for them and to have access to the readings and other resources following the educational session. There were no expectations or requirements related to these modules.
A 3-month follow-up Qualtrics® survey was sent via email to the 13 RNs who had participated in the educational program, access to the modules, and other materials contained in the learning management system. The survey contained 10 questions ranked on a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). All the RNs completed the survey, and all either agreed or stronglyagreed that following the educational program they (a) believed they were well prepared for their new role as an RN and to provide direct patient care in a primary care setting; (b) felt comfortable working with a provider in the primary care setting; and (c) believed their nursing experience prior to participating in the educational program had not prepared them for an expanded role in a primary care setting. The author and the administrative leadership met 3 months after the RNs received the educational program. The content was well received by both the administrative leadership and the RNs.
Due to COVID-19, arrangement of a focus group to solicit feedback was not possible; therefore, the author queried the director of nursing via email on how the educational program and information provided had an influence on the RN participants' orientation in the primary care setting. The director of nursing reported that although there was still much material to be learned during orientation, the course had greatly enhanced the current RNs' orientation because it provided a strong foundation for the practice of skills and concepts in a new setting. Further, the clinical managers expressed that the comprehensive preparation plan had made them feel comfortable about hiring more RNs for expanded-role positions. The director of nursing also hypothesized that in the future, RNs who completed the formal educational program could potentially complete orientation sooner as they would have gained foundational knowledge of primary care using the platform. The administrative leadership requested the author to provide training for educational programs for more recently hired RNs.
With the university's support and feedback received from administrative leadership, the author is developing an enhanced certificate program to prepare senior nursing students and practicing RNs to practice optimally in primary care settings. The program will have additional content related to care coordination, interprofessional education, quality improvement, population health and social contributors of health, electronic health records, policy, and ethics. Participants who complete this enhanced program will be awarded continuing education units and a certificate indicating advanced and focused preparation for practice as an RN in a primary care setting.
This project had many strengths, including the support of both the university and primary care administrative leadership. The newly hired RNs were engaged and demonstrated enthusiasm during each session. The RNs that participated in the meeting provided useful information on the learning needs of newly hired RNs transitioning to a new role. Although this information was very helpful, it would have been beneficial to query all stake-holders, including the other RNs in the expanded role, providers, and support staff regarding other content that may be helpful to include in these educational programs. Although team-based care was threaded throughout the educational program, having a standalone session on patient care delivery models, such as team-based care and collaborative covisits, would help elucidate models of care delivery and increase knowledge on the role expectations. RNs transitioning into primary and ambulatory care are tasked to be leaders in care teams, as well as provide independent and shared visits. Therefore, a special focus in this area would be beneficial as it can provide a deeper knowledge on effective leadership and communication within the team and optimize patient care.
The need for a health care system redesign that expands the role of RNs in primary care settings is well documented (Berkowitz, 2016; Smolowitz et al., 2015; Wojnar & Whelan, 2017). RNs are in a unique position to meet patients' health care needs in the primary care setting; however, prelicensure nursing programs do not typically offer didactic content or a clinical practice experience to prepare practicing RNs specifically for the primary care workforce. A concerted effort among all stakeholders, nursing faculty, and clinical partners is needed to strategize the redesign of the nursing curriculum. Leadership within schools of nursing should provide and support faculty development, educational programs, and clinical experiences for students and RNs interested in this area.
Academic–community partnerships between schools of nursing and health care organizations can create opportunities for RNs to be successful in the primary care work-force, thereby addressing systemic burdens and needs. Primary care settings functioning in antiquated models need redesign to include RNs in expanded roles. In a transformed primary care setting, RNs can manage patients with chronic conditions, such as hypertension and diabetes, take the lead in care coordination and transition, assist patients in self-management of their chronic conditions and preventative care, and be leaders in interprofessional teams. RNs are vital team members as they communicate and collaborate both within and outside of the teams, which can reduce fragmented care. Finally, RNs should be provided lifelong education and professional development opportunities to enhance their knowledge and skills in areas of technology and quality improvement. Primary care settings are changing, and RNs have an opportunity to becomes leaders in this setting. Nursing leaders and stake-holders need to come together to create paths and commit to action to build a nursing workforce that will meet our nation's health care needs.
- Allen, J. W. (2016). Transitioning the RN to ambulatory care: An investment in orientation. Nursing Administration Quarterly, 40(2), 115–121 doi:10.1097/NAQ.0000000000000151 [CrossRef] PMID:26938183
- American Academy of Ambulatory Care Nursing. (2017). American Academy of Ambulatory Care Nursing position paper: The role of the registered nurse in ambulatory care. Nursing Economic$, 35(1), 39–47 PMID:29984958
- Berkowitz, B. (2016). Registered nurses in primary care: A value proposition. Nursing Outlook, 64, 525–526 doi:10.1016/j.outlook.2016.09.006 [CrossRef] PMID:27742078
- Bodenheimer, T., Bauer, L., Olayiwola, J. N. & Syer, S. (2015). RN role reimagined: How empowering registered nurses can improve primary care. California Health Care Foundation.
- Buttorff, C., Ruder, T. & Bauman, M. (2017). Multiple chronic conditions in the United States. RAND Corporation. doi:10.7249/TL221 [CrossRef]
- Ellner, A. L. & Phillips, R. S. (2017). The coming primary care revolution. Journal of General Internal Medicine, 32(4), 380–386 doi:10.1007/s11606-016-3944-3 [CrossRef] PMID:28243869
- Flinter, M., Hsu, C., Cromp, D., Ladden, M. D. & Wagner, E. H. (2017). Registered nurse in primary care: Emerging new roles and contributions to team-based care in high-performing practices. The Journal of Ambulatory Care Management, 40(4), 287–296 doi:10.1097/JAC.0000000000000193 [CrossRef] PMID:28323721
- Ganguli, I., Lee, T. H. & Mehrotra, A. (2019). Evidence and implications behind a national decline in primary care visits. Journal of General Internal Medicine, 34(10), 2260–2263 doi:10.1007/s11606-019-05104-5 [CrossRef] PMID:31243711
- Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. The National Academies Press. doi:10.17226/12956 [CrossRef].
- Josiah Macy Jr. Foundation (2016). Registered nurses: Partners in transforming primary care. https://macyfoundation.org/assets/reports/publications/macy_monograph_nurses_2016_webpdf.pdf
- Keen, A., Embree, J., Lancaster, S. & Bartlett Ellis, R. J. (2017). Feasibility of using mixed-media vignettes to enhance nursing knowledge and attitudes about pain management. The Journal of Continuing Education in Nursing, 48(6), 282–288 doi:10.3928/00220124-20170517-10 [CrossRef]
- Smolowitz, J., Speakman, E., Wojnar, D., Whelan, E. M., Ulrich, S., Hayes, C. & Wood, L. (2015). Role of the registered nurse in primary health care: Meeting health care needs in the 21st century. Nursing Outlook, 63(2), 130–136 doi:10.1016/j.outlook.2014.08.004 [CrossRef] PMID:25261382
- Vanhook, P., Flinter, M., Poghpsyan, L., Dunphy, L. & Barksdale, D. (2018). The American Academy of Nursing on policy: Emerging role of baccalaureate registered nurses in primary care. Nursing Outlook, 66, 512–517 doi:10.1016/j.outlook.2018.09.003 [CrossRef] PMID:30497581
- Wojnar, D. M. & Whelan, E. M. (2017). Preparing nursing students for enhanced roles in primary care: The current state of prelicensure and RN-to-BSN education. Nursing Outlook, 65(2), 222–232 doi:10.1016/j.outlook.2016.10.006 [CrossRef] PMID:28034448
RNS in Primary Care
|Topic||Lecture Content and Readings|
|RNs as Leaders||Role of the RN in Primary Care: Implications for Nursing Education
Institute of Medicine Future of Nursing: Leading Change, Advancing HealthMeeting the Health Care Needs in the 21st Century|
|Introduction to Primary Care and Models of Care||Defining Primary Care
Shared Principles of Primary Care
The Primary Care Provider
The Institute for Healthcare Improvement Triple Aim
Overview of new Models of Care
The Chronic Care Model
Patient-Centered Medical Home
|Health Maintenance||Obtaining a Health History
|Health Promotion/Risk Reduction||Promoting Health
Levels of Prevention
|Patient Education in Diabetes Management||Patient-Centered Approach to Diabetes Care
Living With a Chronic Condition|
|Motivation Interviewing||Change Model|
|Adults With Hypertension||Blood Pressure Classification
Overview of the 8th Joint National Committee
Screening and Risk Factors
Clinical Evaluation, Diagnostic Testing, and Management|
|The Aging Population in the United States||The Three Ds: Clinical Tools (Delirium, Depression, Dementia)