RNs in Primary Care

Opportunities, barriers and hopes for a vital component of healthcare providers.

November 2021 – Repertoire Magazine

Nurses in hospitals are experiencing physical and emotional stress due to COVID. But RNs in the primary care environment aren’t immune.

“They work in a different work environment, but nurses in ambulatory care are facing stress and pressure just like those in acute care,” says Deena Gilland, DNP, RN, NEA-BC, FAAN, vice president and chief nursing officer of Emory Ambulatory Patient Services Operations at Emory Healthcare in Atlanta. “With COVID has come a wave of patients who need care outside the acute care setting. Instead of seeking care in emergency departments, they are coming to our practices.”

With COVID came an overnight boom in telemedicine and telehealth, adds Gilland, who is president-elect of the American Academy of Ambulatory Care Nursing. “That’s a positive thing, but it happened so quickly, we didn’t have the necessary structure and processes in place. That meant additional stress.” Meanwhile, nurses in the ambulatory care setting face the same domestic pressures as their counterparts in the hospital, such as finding child care and monitoring their kids who are doing remote learning.

But the challenges – and opportunities – facing the nursing profession, and all those who rely on nursing, precede COVID and will outlast it. In a report published this spring, “The Future of Nursing:2020-2030,” the National Academy of Medicine made the following points:

As the U.S. population ages, patients will include increasing percentages of older people, many of whom will have multiple comorbid conditions, which will increase the complexity and intensity of the nursing care they require. Increases can also be expected in the number of frail older adults –those who need assistance with multiple activities of daily living, are weak and losing body mass, and have an increased risk of dying within the next 2–3 years.

Nurses will have to expand their roles to supplement a shrinking primary care workforce, provide care to rural populations, help improve maternal health outcomes, and deliver more health and preventive care in community-based settings. A 2020 report prepared for the American Association of Medical Colleges estimated that by 2033, current physician shortages could increase, ranging between 21,400 and 55,200 for primary care physicians, and between 33,700 and 86,700 for specialty physicians. These projections, made prior to the COVID-19 pandemic, take into account decreasing hours worked by physicians, accelerating retirements, and increasing demands for medical care among aging baby boomers.

As the population diversifies in race, ethnicity and other factors, nurses will need to be well-versed in providing care that is culturally respectful and appropriate. Nurses also will be called on to address the persistent and widening disparities in health tied to poverty, structural racism, and discrimination.

Nurses may be called upon to aid in providing mental health care among the general population, stemming from high rates of depression, suicide, anxiety, trauma, and stress due to such challenges as substance abuse, gun violence, and now the lingering effects of the pandemic.

New and broader roles for RNs and advanced-practice RNs (e.g., nurse practitioners) can enhance patient care and access to care, says Gilland. “Nurses can perform care coordination, true population health management and chronic disease management to enhance the work of physicians, who lack the bandwidth to perform all these functions.”

“Care is and will continue to occur more frequently outside of acute care sites,” says Joan Stanley, PhD, RN, FAAN, CRNP, CNL, who is chief academic officer for the American Association of Colleges of Nursing. “It is important that [nurses] are prepared to provide care across the continuum of care. If the U.S. is going to improve outcomes of care and address the inequities in health care, a greater emphasis must be made in prevention and chronic disease management. These are areas of care in which nursing both at the entry-level and advanced levels of practice can make significant contributions to care.”

Team care

The potential role of RNs in the primary care setting has been a topic of discussion for years. According to the Institute of Medicine’s 2011 report “Future of Nursing: Leading Change, Advancing Health, “traditional nursing competencies, such as care management and coordination, patient education, public health intervention, and transitional care, are likely to dominate in a reformed healthcare system as it inevitably moves toward an emphasis on prevention and management rather than acute [hospital] care.”

Some have used the term “team care” to describe a physician practice that makes full use of the talents and skills of all staff members, including RNs. In 2008, Peter Anderson, M.D., a family physician in Newport News, Virginia, described in Family Practice Management his practice’s “family team care” system, which, he said, improved professional satisfaction, quality of care and financial performance. Most patient visits can be broken down into four distinct components, he wrote:

Part 1: Data-gathering.
Part 2: Analysis of data and pertinent physical exam.
Part 3: Decision-making and development of a plan.
Part 4: Implementation of the plan and patient education.

“During a traditional office visit, the physician completes the majority of all four components. But in the team care model, the clinical assistant [typically an RN or LPN, or a capable medical assistant] gathers data according to specific protocols and communicates that information to the physician, in the presence of the patient, when the physician enters the exam room (Part 1). The physician then analyzes the data, conducts the exam, determines the diagnosis and develops the treatment plan (Parts 2 and 3).

“The clinical assistant documents the findings and additional information elicited by the doctor during the exam. The physician discusses the treatment plan with the patient and the clinical assistant and exits the room. The clinical assistant closes the visit with the patient, reiterating the physician’s instructions and providing prescriptions, referral information and patient education materials as directed by the physician (Part 4).”

Beyond the physician office

In June 2016, the Josiah Macy Jr. Foundation convened a group of national experts to address the need to transform primary care and promptly identified the need to change the culture of healthcare and transform the practice environment. The outcome of those proceedings were published under the title “Registered Nurses: Partners in Transforming Primary Care.”

The report emphasizes the need to overcome the limited ways in which many primary care practices currently use RNs, e.g., telephoning prescriptions to pharmacies or performing administrative duties.

“Primary care practices should evaluate the skill mix of current team members to ensure that their contributions are optimized, and either hire RNs into enhanced roles or reconfigure the roles of those already on the team,” the experts concluded. “The RN roles should include care management and coordination for aging and chronically ill patients and those with increasingly complex health needs; promoting health and improving patients’ self-management of prevention and behavioral health issues; and placing greater emphasis on transitional care, prevention, and wellness. Practices should optimize the potential of RNs, allowing them to spend ample face-to-face time with patients.”

RNs also can help improve transitional care, as patients move between hospitals, other care facilities, and home. Further, they can help improve patient engagement, quality scores, and team collaboration using health assessments, patient education, motivational interviewing, medication reconciliation, care planning, and more.

The human element

Because of their clinical knowledge, experience, and hands-on work with patients, nurses are uniquely qualified to step up their role in the outpatient clinic, says Sean DeGarmo, PhD, RN, ACNS-BC, FNP-BC, ENP-BC, director of Advanced Practice Initiatives and Certification Outreach at the American Nurses Credentialing Center. “Nurses operating at their full scope of practice are skilled at communicating with patients and the healthcare team – a very, very vital role in the practice.” Using that skill, they keep in touch with patients between visits, answer questions, and – because they understand diagnostic tests and procedures –help make sure patients are scheduled appropriately and understand the plan of care, he says.

“Nurses are skilled in dealing with the human responses to the disease process, not just the disease itself.”

“We need to make sure the public – and even nurses themselves – see nurses as capable of providing care at all ends of the spectrum, not just as comforters or as the ones to carry out doctors’ orders,” says Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, who is the director of nursing programs and co-lead for Project Firstline in the Department of Nursing Practice & Work Environment at the American Nurses Association. “If nurses are to feel valued, they must be allowed to practice at the top of their license.” Nurses can address the primary care supply and demand gap starting with increasing and optimizing roles as nurse practitioners. As case managers, for example, they help patients and the community understand steps they can take to remain well, a process that takes place largely outside the doctor’s office, including on the phone or video, she says.

“We have an increasing number of advanced practice nurses who can help provide care in the office, but room has to be made for them to enter that space.”

Barriers

Proponents argue convincingly that RNs can and should be allowed to manage patient care across the continuum of care. But are they?

“It has been happening around the country for the past five to 10 years,” says Gilland. While not universally adopted, “it’s an evolution,” she says. With changing payment and reimbursement models, telehealth and today’s emphasis on population health, the transformation will speed up. “The time is now. The spotlight is on.”

Authors of a September 2018 article in Nursing Outlook magazine, “The American Academy of Nursing on policy: Emerging role of baccalaureate registered nurses in primary care,” wrote that high-performing teams, including RNs, who participated in the Robert Wood Johnson Primary Care Teams’ “Learning from Effective Ambulatory Practices (PCT-LEAP)” program played a pivotal role in preventive health and chronic care management and practiced autonomously in many of these domains. “BSN-RN responsibilities in high-performing primary care organizations have been found to increase access to healthcare services, decrease hospital re-admission, ER use, and overall costs of care, and improve quality of care, patient outcomes, and staff satisfaction,” they said.

Nurse-led clinics have proven to reduce lengthy backlogs of care, says Boston-Leary. “Data shows they are successful and, over time, many in the community are seeing the benefits.”

DeGarmo says that studies have demonstrated that practices with strong working teams, in which everyone works to their highest level, function better and yield better patient outcomes. “In a shared-decision-making environment, everyone has a voice. Instead of someone telling staff, ‘I want you to do this,’ you find people speaking up with, ‘Is this the best treatment option and has it taken into account what matters most to the patient?’ It leads to a more functional and productive work environment.”

But barriers still exist. The Macy Foundation identified four of them:

Many RNs in primary care still spend much of their time on patient triage, sorting out who needs to be seen immediately and who can wait – important functions, but functions that take away time that could be spent on chronic care management, care coordination and preventive care.

Some state laws inhibit RNs from exercising the full extent of their education and training. Even when state law supports full practice authority, healthcare organizations sometimes restrict RNs from practicing to the full extent of their licensure.

Much of the work that RNs and other primary care team members currently perform is not directly reimbursable under the fee-for-service payment model, meaning that new payment
models are needed to facilitate the growth of primary care teams that include RNs.

Perhaps most important, many RNs are not exposed consistently to the full range of primary care content in the classroom or through instructional clinical experiences, which overwhelmingly focus on inpatient and acute care. As a result, RNs may lack skills and competencies essential to functioning effectively in primary care.

Educating tomorrow’s nurses

Changes such as these call not only for enlightened, capable leadership among non-acute providers, but for new emphases in nursing education.

“Nursing education programs have historically emphasized preparing students for inpatient acute care and medical and surgical nursing,” wrote the authors of the National Academy of Science report on the future of nursing 2020-2030. “Consequently, too few nurses today are adequately prepared to practice in non–acute care settings. To address the growing need for primary care providers, educators will have to increase coursework and student clinical experiences in primary care settings, which in turn could lead to more graduates choosing careers in primary care and ambulatory and community-based settings.”

In fact, more nursing schools are adding primary care content at the undergraduate level, says Joan Stanley of the American Association of Colleges of Nursing. In addition, nursing schools are providing nursing students with practical experience in non-acute care settings, including primary care.

“AACN has strongly endorsed the need to strengthen academic-practice partnerships in our ongoing work with the American Organization for Nursing Leadership and in our 2016 publication, ‘Advancing Healthcare Transformation: A New Era for Academic Nursing,’” she says. “We also have encouraged schools to develop diverse partnerships, which include primary care, public health, and other non-acute care partnerships.”

The result – it is hoped – will be growing enthusiasm on the part of nursing graduates to work in non-acute-care settings.

“Over the past five years or so, we had seen a great interest among nursing graduates who want to practice in ambulatory care,” says Gilland. “They understand that tackling our healthcare crisis starts in the non-acute-care setting.”

Nursing stats

An estimated 600,000 baby boom RNs are expected to leave the workforce by 2030, per the National Academy of Medicine’s “Future of Nursing: 2020-2030” report. “The exit from the workforce by so many experienced RNs (about 70,000 per year) means that health care delivery organizations that depend on RNs will face a significant loss of nursing knowledge, clinical expertise, leadership, and institutional history.”
Forty-two percent of RNs in private medical practice are older than age 50.
Just 5% of RNs work in a private medical practice (clinic, physician), while 27% work in an inpatient unit (not a critical access hospital), 11% in a critical access hospital, and 9% in a hospital-sponsored ambulatory care setting, per the NAM report.
Based on findings from the American Association of Colleges of Nursing’s annual survey conducted in Fall 2020, nursing programs offered at the entry-level baccalaureate, master’s and Doctor of Nursing Practice have seen more than 15 years of continuous enrollment growth.

Retaining the Workforce

Health systems explore ways to recruit, retain staff amid variant surge; prepare for long-term changes

Twenty two percent of nurses providing direct patient care indicated that they may leave their current position within the next year in a recent McKinsey survey.¹ A significant strain exists in the healthcare workforce due to the COVID-19 pandemic. Health systems recognize the unique challenge and are responding with wage increases, recruitment increases and one-time bonuses. These are the top tactics used during the past three months to maintain and retain a strong nursing workforce.²

Nursing turnover and vacancy rates have increased four to five percentage points in the past 12 months. This is all during a time when health systems are trying to catch up to meet increased demand as patient volumes return and exceed 2019 levels in the U.S. Expanded clinic hours, increased physician productivity expectations, optimized operating room scheduling and expanded operating room hours are all critical challenges hospitals cite3 and to meet them lies on the capacity and well-being of their healthcare workforces.

Operations impacted

Health systems have had to change their care model, reduce inpatient capacity, report reductions in operating room and ambulatory clinic capacity, increase emergency department diversion and increase length of stay as more than 80% of respondents reported continued challenges with nursing workforce coverage. Challenges with broader clinical support staff coverage was reported by 60% of respondents. The McKinsey survey represented 100 respondent hospitals across the U.S. with more than 200 beds, collectively representing about 10% of all hospital beds in the country.

Hard hit South

Hospitals are making do with available resources and staff in the hard hit states in the South. Hospitals in Georgia had to scale back services due to lack of staff and some halted elective surgeries. According to The Atlanta Journal-Constitution, experienced nurses are quitting in Georgia, changing jobs or just hanging on. The Delta variant struck the South harder than other areas of the country and hospital staff are exhausted battling COVID-19’s fourth wave.

Because of healthcare staffing shortages in Mississippi, 771 medical-surgical and 235 ICU beds were reported unused in August. More than 70 Mississippi hospitals had collectively asked the state for about 1,450 healthcare workers to make use of the available beds during the Delta variant surge. A recent health order certified Mississippi’s Emergency Medical Services workers to provide care for patients in state-licensed hospitals as Mississippi saw its highest number of coronavirus-related hospitalizations since the virus entered the state in March 2020.

According to McKinsey, healthcare systems are managing short-term, pandemic-era workforce challenges and preparing for long-term changes to enhance the workforce and patient experience.

References

¹2021 McKinsey Future of Work in Nursing Survey, ² McKinsey COVID-19 Hospital Insights Survey (July 2021), ³ McKinsey COVID-19 Hospital Insights Survey (July 2021)