Shifts in care delivery require a shift in nurse preparation.
The increase in the aging population, surge of chronic diseases, passage of the Affordable Care Act, and trends transitioning to value-based reimbursement have resulted in a demand for greater access to primary care services. As a result, primary care team–based models have emerged to meet patients’ needs and address the primary care provider (physician, nurse practitioner, physician assistant) shortage. For example, the interprofessional medical home model expands the role of RNs with a bachelor of science in nursing (BSN-RNs).
An American Academy of Nursing policy statement on the emerging BSN-RN role in primary care states that adding the RN to the primary care team can provide skill sets necessary to meet quality and practice performance outcome measures. In this article, we describe this emerging role and its value in primary care, offer an overview of the various strategies implemented to promote education and training of RNs for practice in primary care (including two school of nursing experiences), and discuss the challenges that must be addressed to ensure BSN-RNs can practice at the top of their license in these settings.
Emerging role and value
Across the United States, primary care practices have begun to examine how integrating BSN-RNs can support achieving the Quadruple Aim, which focuses on improving population health (access and quality), patient experience, provider experience, and lower costs. BSN-RNs represent an untapped resource in primary care, and the holistic approach that nursing practice provides can contribute to improved patient outcomes. For example, BSN-RNs use critical clinical judgement skills to help the medical team address patient-centered health goals, identify and address social determinants of health, ameliorate health literacy issues, and support the medical treatment plan. In addition, they perform patient education, population health data analytics, telephone triage, quality improvement, patient coaching, care coordination, and advocacy to support client self-management and care management. One of the most valuable ways in which the role can support practice viability and outcomes is through Medicare Annual Wellness Visits, which are within the RN scope of practice. BSN-RNs also contribute to behavioral health integration using health assessments and other interventions, and they serve as leaders to promote teamwork and collaboration via relational and communication skills that guide the team in coordinated care delivery.
Several organizations—including the Robert Wood Johnson Foundation, the Institute of Medicine, and the National Academies of Medicine—have called for increased integration of BSN-RNs into primary care teams. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity report, as well as changes to the American Association of Colleges of Nursing The Essentials: Core Competencies for Professional Nursing Education, recognize the need for BSN-RNs to be prepared to practice at the top of their license in primary care settings. (See Full scope of practice.)
- Use nurse knowledge, skills, and clinical judgment to determine appropriate actions based on professional practice standards, state nurse practice acts, and legal regulations.
- Make autonomous nursing care decisions at the point of care, determine the best nursing care plan for the patient, advocate for the patient’s needs, and evaluate patient response.
- Provide nursing interventions to support patient outcomes.
- Mobilize resources to provide safe, high-quality patient care.
- Serve in leadership roles and participate in decision-making at an organizational level through involvement in policy decisions, shared governance councils, and clinical practice councils.
- Engage in policy and advocacy efforts to support the profession and its contributions to patient outcomes.
Nurse education and preparation
Baccalaureate and graduate nursing programs must aim to expand their curriculum to incorporate a full scope of practice in primary care. This includes curriculum related to care coordination, transitions, and chronic disease management with more emphasis on an independent role in community-based primary care. Currently, few, if any, nursing schools expose students to primary care–focused nursing practice.
Unlike acute care settings, few primary care practices have the robust orientation programs necessary to meet the requirement of a more autonomous RN practice. In fact, many primary care clinics that emphasize the medical provider as the main deliverer of reimbursed services haven’t fully realized the benefits of adding the wide-ranging expertise and clinical judgement of BSN-RNs. In addition, many medical providers are unfamiliar with the educational preparation and scope of practice of these nursing professionals, and few are exposed to primary care practice models that fully integrate nursing expertise.
In 2016, in response to the need to transition nursing education to support RN integration in primary care, the Health Resources and Services Administration (HRSA) funded nine academic nursing institutions to develop educational models that allow BSN-RN students to gain more clinical experience in community settings.
In 2018, HRSA called for applications for the Nurse Education, Practice, Quality and Retention (NEPQR)—Registered Nurses in Primary Care Training Program to help current and future nurses practice at the top of their license on an interprofessional team. A total of 42 programs across the country were funded for this 4-year cooperative agreement with HRSA to recruit, educate, and train nursing students and current BSN-RNs for high-level practice roles in community-based primary care. The goal is to increase access to care and improve population health with an emphasis on chronic disease prevention, including mental health and substance use conditions.
Implementation strategies
A review of publicly available abstracts for grants awarded under HRSA’s program shows that of the 42 grantees, 37 are nursing schools and five are healthcare providers or other entities that offer primary care services and have partnered with schools offering BSNs. Grantees, which include both public and private nursing schools, are located in urban and rural areas in 26 states.
These funded programs have designed various mechanisms to fulfill the purpose of the grant program. Strategies for didactic and practicum exposure to primary care nursing practice include integrating primary care–focused content into existing courses, adding new courses to the undergraduate curriculum, and developing a post-baccalaureate certificate.
As part of the cooperative agreement, grantees must develop immersive curricular experiences focused on primary care nursing practice, as well as continuing education for current RNs, nursing faculty, and preceptors. Many have created professional development continuing education modules. Students in immersive experiences must engage in at least 150 practicum hours with a BSN-prepared preceptor in a primary care setting. At least three program abstracts noted building a post-baccalaureate nurse residency program to prepare RNs for primary care practice.
In addition to program-specific evaluation measures, HRSA has asked funded programs to examine the impact of these experiences using a series of shared measures, which include student knowledge, staff and student self-efficacy and performance, provider and patient satisfaction, partnerships, and healthcare access and cost.
During the pandemic, grantees received additional funding through the CARES Act to support COVID-19 prevention and response. This funding was especially helpful as higher education pivoted to virtual curriculum delivery. (See Program examples.)
Western Carolina University School of Nursing
Since 2016, Western Carolina University School of Nursing has integrated primary care–focused content into its undergraduate bachelor of science in nursing (BSN) curriculum. Students opt into an immersive practicum in primary care with a trained RN preceptor as part of their community/mental health and capstone courses. Students experience various primary care BSN-RN roles at partner practice sites, and as part of the capstone course, they train at a primary care site with a preceptor to hone their skills in population health, quality improvement, and care coordination and management.
Western Carolina University is one of three nursing schools to receive two rounds of funding through NEPQR. In 2018, the primary care nursing program expanded to include development and execution of a 6-month post–BSN-RN residency/fellowship. This unique competency-based program has a robust didactic curriculum and intensive preceptor-guided practicums with a strong emphasis on developing effective care coordination and management skills to support patient outcomes. To date, 54% of residency/fellowship program graduates have gone on to practice in primary care settings, including rural practices, and 75% are practicing in community-based settings across Western North Carolina.
Frances Payne Bolton School of Nursing
The Frances Payne Bolton School of Nursing, Case Western Reserve University, uses a two-pronged approach to implement strategies at the school and primary care setting. The nursing school completed a faculty survey to identify gaps in primary care integration and then formulated a plan for bridging those gaps. Next, faculty champions led implementation activities within their courses to address the primary care component. For example, the medical-surgical sophomore level course added three post-conference clinicals on care transitions and coordination and a 1-day clinical in a primary care setting. In addition, primary care opportunities, including population health and quality improvement, became part of the senior capstone experience.
In the primary care setting, a preceptor module series was developed with training and other continuing education opportunities related to quality improvement and telehealth. In addition, a primary care liaison, integrated into the clinic workflow, led a clinical microsystem assessment using the Dartmouth Hitchcock Medical Center tool. The assessment found that BSN-RNs need to work within interprofessional teams and examine opportunities to practice to the top of their license. A unit-based council formed to identify problems and generate solutions empowered nurses to lead quality-improvement initiatives and unit-based projects.
Ongoing challenges
Despite efforts to develop the supply of BSN-RNs prepared to practice at the top of their license in primary care, many practices still don’t understand how to effectively integrate them. Role confusion is further complicated because few medical providers have been exposed to BSN-RNs working to their full scope of practice. Too frequently, the focus for staffing has been on seeking the lowest-cost staffing model, such as medical assistants.
Other challenges that hinder full integration of BSN-RN expertise include RNs’ own limited understanding of what practicing at the top of their license entails. They can’t clearly articulate the impact of nursing interventions on patient outcomes and practice productivity and efficiency. To ensure nurses can advocate for their role in primary care, they must develop strong interprofessional leadership skills, data analysis expertise to manage populations, and healthcare business competencies. Nursing education programs must provide additional emphasis and modeling of RN roles that exemplify full practice. Advocacy must ensure that laws and regulations provide title protection for licensed nurses and recognize BSN-RNs as qualified professionals to perform reimbursable nursing services.
Perhaps the greatest challenge is the need for strong data to support the business case for BSN-RN integration. Measurable primary care nurse-sensitive metrics must be captured in the electronic health record (EHR) and continually monitored and evaluated. These metrics will facilitate cost vs. benefit information to demonstrate how BSN-RNs can lower organization costs. Unfortunately, most EHRs don’t capture metrics that reflect RNs’ contributions to outcomes. The HRSA NEPQR grantees collect data to measure BSN-RN impact in primary care, but this work is in its infancy. In conjunction with efforts by the American Nurses Association and other professional organizations such as the American Academy of Ambulatory Care Nurses, this information quantifies nurse-sensitive outcomes and the value of embedding BSN-RNs to provide critical evidence for integrating these nursing professionals into primary care teams. In the Future of Nursing 2020–2030 report, the National Academies of Medicine has called for unique nurse identifiers to better capture RN interventions.
More work to do
Emerging opportunities exist for BSN-RNs to practice full-scope, autonomous, holistic nursing in primary care. However, more work is required to address role clarity, enhance nurses’ understanding of what full-scope RN practice looks like, develop the business case for RN integration onto the primary care team, and advocate for policy changes that recognize RN contributions for service delivery and reimbursement.
Mary A. Dolansky is the Sarah C. Hirsh Endowed Professor at The Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, Ohio. Kae Rivers Livsey is an associate professor at Western Carolina University in Cullowhee, North Carolina.
Editor’s note: This article coincides with our new Nurse Influencer blog on primary care, available at myamericannurse.com.
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