The perspectives of nurse practitioners and physicians on increasing the number of registered nurses in primary care

Abstract

Primary care providers, including physicians and nurse practitioners, described the importance of increased RN staffing in primary care. Adequate RN staffing improves the quality and safety of patient care, alleviates provider workload, and increases care continuity in primary care practices.

As more patients are living with chronic disease, which is expected to reach 157 million Americans by 2020, it is crucial to ensure that there is an adequate workforce to deliver timely and high quality primary care to patients who need to manage their conditions (Bauer, Briss, Goodman, & Bowman, 2014; Wu & Green, 2000). Traditional models for delivering primary care, such as the use of solo providers, are threatened by increased workload, growing complexity of patient visits due to multi-morbidity, and an expected deficit of 52,000 primary care physicians by 2025 (Milani & Lavie, 2015; Petterson et al., 2012). This strain jeopardizes patient safety and quality of care because it is difficult for a solo provider to complete all recommended care management tasks singlehandedly (Yarnall et al., 2009). As a result, team-based care models, such as patient-centered medical homes or accountable care organizations, have increasingly been implemented to increase access to care, reduce cost, and improve quality by delivering care through interprofessional teams (Auerbach et al., 2013; Grumbach & Bodenheimer, 2004). Organizations are increasingly expanding interdisciplinary primary care teams that consist of health care professionals from multiple disciplines, such as physicians, nurse practitioners (NPs), pharmacists, and social workers (Auerbach et al., 2013; Ghorob & Bodenheimer, 2015). There is a gap in the literature, however, about the increased staffing of registered nurses (RN) within primary care.

RNs can complete a variety of clinical nursing tasks and responsibilities within primary care teams (Smolowitz et al., 2015). A recent systematic review investigated the roles of RNs in primary care across six countries and found that RNs are responsible for clinical care, pharmaceutical management, and care coordination (Norful, Martsolf, de Jacq, & Poghosyan, 2017). However, some organizations have increased the role of non-nursing staff such as medical assistants (MAs) which may partially be driven by lower salaries for MAs compared to RNs (Bodenheimer, Willard-Grace, & Ghorob, 2014). Moreover, there is often confusion about the difference in roles of RNs compared to NPs, who are advanced practice registered nurses that in most U.S. states can evaluate, diagnosis, prescribe medications, and determine a treatment plan for patients (Bishop, 2014). This confusion may prevent organizations from seeing the benefits of staffing both RNs and NPs within the same primary care team.

Varying perspectives about the role of RNs in primary care can lead to RN understaffing and inhibit the benefits of RN expertise within primary care teams (Smolowitz et al., 2015). Prior studies demonstrate the link betwen RN understaffing levels and suboptimal patient oucomes such as patient falls, increased medical errors, job dissatisfaction and a decreased quality of care (Dellefield, Castle, McGilton, & Spilsbury, 2015; Lee, Blegen, & Harrington, 2014; Martin, 2015). However, most studies have predominantly investigated RN staffing levels within hosptial or nursing homes and little is known about the effect of RN staffing levels in primary care.

While organizations such as the American Academy of Ambulatory Care Nurses have released position statements in support of increased RN-led care, primary care providers (PCPs) must be willing to relinquish some of their traditional tasks and responsibilities to non-PCP team members (AACN, 2012; Freund et al., 2015). To date, however, there is no evidence of the perspectives of PCPs when increasing RN staffing in primary care. The purpose of this study is to elicit PCP perspectives about the use of RNs in primary care, including how RNs can optimally be integrated into primary care teams and the perceived impact of increased RN staffing in primary care.

Methods

This study was part of large investigation on primary care delivery and safety that qualtitatively examined the impact of primary care interprofessional teams on practice and patient outcomes from the perspectives of PCPs (Norful, de Jacq, Carlino, & Poghosyan, 2018; Poghosyan et al., 2017). We used a qualitative descriptive design to obtain data from PCPs through individual in-person interviews. The research team included a primary care NP, a physician, a registered nurse, and a health services researcher with expertise in qualitative research design. The study was approved by the Institutional Review Board of Columbia University Medical Center. First, we developed an interview guide based on existing evidence about RNs in primary care (Bodenheimer & Mason, 2016; Norful, Martsolf, de Jacq, & Poghosyan, 2017) and task allocation within primary care teams (Edwards et al., 2015). Semi-structured, open-ended questions in the guide were designed to obtain information about how RNs are currently being utilized in primary care practices and the PCP perspective of optimal RN utilization. Examples of the questions include: 1) “Describe the roles and responsibilities of RNs in your practice” and 2) “From your perspective, how do RNs within your team contribute to the goals of patient care?”

A purposive convenience sample of PCPs were recruited from primary care practices in New York State (NYS). We contacted practice managers and PCPs within the research team’s professional network to inform them of the study and ask for their help with the recruitment. We used a snowball sampling technique and encouraged PCP participants to recommend their colleagues who may have an interest in participating in the study. Interested PCPs contacted the researchers via email and provided a time and place convenient to them for the in-person interview. One researcher (AN) with extensive experience in qualitative research and also practicing as a primary care NP, conducted all interviews. A reflective journal was kept by the interviewer to reduce bias. PCPs were asked to complete a demographic form to report their age, sex, education level, years of experience, and practice setting. Written consent was obtained prior to each interview. All interviews were audio-recorded to ensure descriptive validity and lasted from 25–45 minutes. No one else was present during the interview except the researcher and participant. Field notes were kept by the resercher during the interview. At the end of the interview, each participant received a $20 gift card.

All audio recordings were professionally transcribed following each interview. Data analysis and subsequent interviews were conducted concurrently to allow the researchers to further explore emergent themes. Transcribed data were imported into NVIVO v11 for analysis. Each transcript was read and checked against audio files to ensure accuracy of transcription. Two researchers (AN and LP) independently coded each transcript and met weekly, in-person, to refine codes, group them into categories and discuss emerging themes. Perspectives of NPs and physicians were compared throughout the data analysis. Data saturation was reached after 26 interviews, at which point no new information was emerging from the interviews. Two of the PCP participants (1 NP and 1 physician) were asked to review the findings to ensure interpretive validity.

Participant Characteristics

The final sample consisted of twenty-six PCPs (12 physicians and 14 NPs) (See Table 1). The mean age of the participants was 43 years and the mean years of PCP experience was nine years. Seventy-seven percent of the PCPs were female, and the majority practiced in an urban setting. Practice types included private physician-owned practices (n=5), university-affiliated clinics (n=9), hospital-affiliated clinics (n=11), and a federally qualified health center (n=1).

Table 1.

Participant Characteristics

Characteristics	Participants (N = 26)
Occupation, No. (%)
Physician	12 (46)
Nurse Practitioner	14 (54)
Age, years
Mean (SD)	41.36 (11)
Range	28–66
Sex, No. (%)
Female	20 (77)
Highest Degree, No. (%)
Master’s	5 (19)
Post-Master’s	3 (12)
Doctor of Medicine	11 (42)
Doctorate	7 (27)
Main Practice Site, No. (%)
Private Practice	5 (19)
University-Affiliated Clinic	11 (42)
Hospital-Affiliated Clinic	9 (35)
Government funded Clinic	1 (4)
Geographic Location, No. (%)
Urban	17 (65)
Suburban	8 (31)
Rural	1 (4)

Findings

Three themes emerged from the qualitative data: 1) How RNs are integrated into primary care teams; 2) Improved quality, safety, and continuity of care with increased RN staffing; and 3) Alleviation of PCP workload.

How RNs are integrated into primary care teams

PCPs described several ways that RNs were integrated into their primary care teams including RNs performing care responsibilities before, during, and after the patient visit. Predominantly RNs completed patient education, immunizations, and point of care testing, such as a rapid strep test. A physician in a hospital-affiliated clinic said that RNs are, “mainly doing injections, like vaccines, pain medications, any rapid tests, pregnancy tests.” Some PCPs used standing orders so that the RN can be self-directed and complete clinical tasks to meet the patient’s care needs immediately upon triage. For example, a NP in a community practice said that PCPs use standing orders for, “certain blood tests, like HIV testing, or immunization titers like hepatitis B or MMR.” The ability to complete these preliminary clinical tasks during triage and before the PCP-patient encounter is dependent on RN autonomy and the standardized orders enable this RN-led care. For example, in one urban community clinic patients are identified by diagnosis and RNs perform diagnosis-specific tasks guided by the standing orders to meet the needs of the individual patient. A physician who also acts as a medical director described, “we’ve stratified the health risks of patients so that we have a level 1, 2, and 3. [RNs] have standing orders and then we just sign off on the charts.” The perceived benefit of RN-led triage is team efficiency by anticipating the patient needs, such as lab testing, education, or immunizations, before the PCP enters the exam room. A NP in a private practice said, “it’s better to see what [patients] are coming in for, to anticipate their needs before the provider even walks into the exam room.”

In addition to responsibilities before the PCP-patient encounter, RNs were described as making significant contributions to care management at the end of the patient visit. Some RNs were specifically identified as the “discharge RN.” Following the PCP-patient encounter, discharge RNs review the PCP orders and determine the education or care coordination needs of the patient to promote compliance with the plan of care. A physician working in a patient-centered medical home explained, “We’ll have all our orders in and the nurse will make sure that [the patient] understands what medications they’re on, why they’re taking them, how are they going to make it to their next appointment…any blocks that might come up.” The RNs further can screen patients for additional needs such as social work interventions or other community resources.

The amount and extent of RN responsibilities varied across PCP reports and were based on the number of team members available and the size of the practice. Practices with 3 or more PCPs were more likely to employ both a MA and RN that each completed their own specific clinical responsibilities. A physician in a large multi-provider practice described that after the MA prepares the exam room and performs initial patient interviewing during the visit, the RN comes in to perform a thorough history of the patient’s presenting diagnosis. After the PCP-patient encounter, a second RN is responsible for assessing the patient’s discharge needs. In comparison, PCPs in smaller practices reported that the same RN performs a myriad of all triage, clinical visit, and discharge tasks, some with and without a MA present. One NP said that the “[RN] floats amongst the providers” and “if there’s something urgent then they call us.”

In addition to the extent of the RN responsibilities described, PCPs were adamant about how RN contributions to primary care teams is crucial to the ability of the team to function effectively. A physician in an accountable care organization said, “it’s not just the physician being the driver. It’s the nurse, it’s the MA. We all have to take ownership over our patient.” A second physician in a small private practice said, “I want to use my nurse more as the leader of the team. I want her to be aware of how I practice. I need her to be kind of like the mover and the shaker for me.”

Improving quality, safety, and continuity of care with increased RN staffing

Almost all PCPs perceived that when more RNs are incorporated into primary care teams, there is increased quality of care, patient safety, and continuity of care especially as the volume of patients and complexity of care needs increases. Further, RNs help to ensure that no important care management tasks are left undone or omitted. A physician in a large community clinic said, “the whole idea for these complex patients is that you shouldn’t have to leave anything out of the visit because that’s where you get in trouble. But if you have a discharge nurse where you say ‘look this is what they need and they’re going to need 30 minutes for someone to go over this in a way that they are going to get it.’” RNs were also described to have an important role in individualizing patient care through shared decision making. A NP said that RNs often “educate the patient on their illness, involve them with decision-making processes. Physical activity and setting targeted individualized care planning…that’s really the RN skills.” By doing so, the RNs are viewed as “being well informed of the patient’s medical, psychosocial, and health issues which can shape a patient’s adherence to the plan of care.”

Patient follow-up by RNs was reported to enhance continuity of patient care. Specifically the RN role was viewed as vital for timely review of diagnostic findings and if abnormal, RNs contact the patient to provide relevant patient education and assist with scheduling a subsequent in-person visit. Patient follow-up by RNs was also perceived to increase patient adherance to the plan of care by addressing any patient questions or concerns through education and reinforcement. A physician in a private practice said that he believes that patient follow-up by RNs not only improves patient compliance but also helps them to identify when a higher level of care is appropriate. He explained: “I can ask my RN to follow up and provide additional teaching on how to use an inhaler properly, how to come up with an actual plan for asthma, so that if they’re feeling ill at home, when to come in, when to utilize our clinic, and when to use the emergency department.” A NP also perceived that patient follow up by the RN leads to increased medication adherence and said that “especially with the high-risk patients, they need a team behind them. Sometimes hearing it from one person and then hearing it from another person, that same message…I find that reinforcing…to medication, to diet, to keep up with appointments.”

While much of the described patient follow-up occurred via telephone, some PCPs talked about increased continuity of care through in-person RN follow-up with patients. For example, one physician explained that having an RN on the team helps to ensure that more than one clinician is actively co-managing the progress of the patient’s diagnosis and needs:

“A lot of patients for me have wound care issues. I’ll look at it, I’ll determine what needs to be done, and then I have them see the RN to dress the wound and clean the wound. This way the RN can see what the wound looks like now, because that patient is going to have to come back the next week. At least someone who has seen the wound initially can keep following up. I’ll have them come back to the RN the week after to monitor the progress.”

Alleviation of PCP workload

In addition to RN contributions to clinical care management, PCPs also reported that the increased number of RNs in their practices helps to reduce PCP workload and the strain to complete all care management tasks singlehandedly. Further, the presence of RNs helps with the efficiency of team-based care. For example, a NP in a university-based clinic said, “some of the patient education pieces of our job, which we really like to do as NPs, but we’re pressed for time…an RN can help with that…especially all the preventative care, healthy diet, exercise…a RN can do that really well in conjunction with us.” She also said, “it’s not that you want to be disconnected from your patients as an NP, but you also want to be able to have your time with your patient and then onto the next one because another patient is waiting.”

A physician in a private practice explained that since RNs can anticipate a patient’s needs prior to the PCP-patient encounter, workflow is enhanced. He explained, “sometimes we get patients who are here for abdominal pain and then not until, once they’re in the room with us, do we realize that they maybe need a pregnancy test or a pelvic exam. So I feel like having an RN in the office setting helps to improve the efficiency of the workflow.”

Almost all PCPs reported that staffing more RNs in primary care allows them to see more patients daily and frees up time for more required administrative tasks. A NP shared that she is able to work together with a RN to provide more detailed patient education in a timely manner thereby freeing up her time for more clinical patient visits. She explained that if there is individualized patient education that needs to be completed then she tells the patient, “we have a [RN] colleague in our practice who can spend half an hour with you talking about nutrition in a detailed way.’” By having an RN to allocate education responsibilities to, the PCP is able to complete other tasks and responsibilities is a timelier manner. A physician in an urban community clinic who was actively working to increase the number of RNs in her practice described how the increased presence of RNs in primary care could further influence PCP practice: “We’d have more time for documentation but also important things like following up on imaging in a very timely fashion. There is also not enough time in our day for reviewing updated guidelines.”

Discussion

In this study, we explored PCP perspectives about RNs in primary care, including how RNs are optimally integrated into primary care teams, what roles RNs play, and what is the perceived impact of increased RN staffing in primary care. Our findings indicate that PCPs rely on RNs to provide a myriad of tasks such as collecting a patient’s medical history, completing patient education, performing immunizations, and carrying out point of care testing. Further, this study demonstrates that RNs are perceived to play a vital role in coordinating patient care; before, during, and after the PCP-patient encounter. This, in turn, provides PCPs with more time for patient visits, administrative tasks, and helps to ensure that PCPs have time to remain up-to-date on current evidence-based practice recommendations.

Our findings also illuminate that RNs play a critical role dedicated to care coordination and post-visit patient follow-up. This designated post-visit RN-patient encounter, often called the ‘discharge’, yields a greater amount of time allotted to individualizing patient care based on social, financial and educational determinants. Individualized patient-centered care has widely been shown to improve patient outcomes (Elwyn et al., 2014; Inzucchi et al., 2015; Rathert, Wyrwich, & Boren, 2013). These findings are consistent with recommedations in prior studies and the position statement of the American Academy of Ambulatory Care Nurses which recommend the increased use of RN-led care coordination to improve quality of care (AAACN, 2012; Haas & Swan, 2014). Further, individualized care can influence a patient’s adherence to their plan of care. Given the current strain for PCPs to meet the demands of complex chronic disease care partly due to concurrent provider shortages, RNs are in a prime position to contribute their clinical expertise and help alleviate the strain.

While the findings in this study demonstrate the potential positive effects of increased RN staffing in primary care, some organizations may be reluctant to hire RNs based on increased cost (Aiken, 2008). Not hiring RNs are sometimes attributed to the variability and and/or lack of reimbursement models for RN-specific tasks. However, it is important to illuminate that studies have shown that RNs in primary care can increase net revenue through new payment mechanisms such as the Centers for Medicare & Medicaid Services chronic care management program (AACN, 2012; Basu, Phillips, Bitton, Song, & Landon, 2015). Further, a study by Basu et al. (2015) determined that net revenue was the greatest when chronic care management was delivered cooperatively by PCP and RN care managers. As a result, PCPs may be a cost-ineffective option for care management, given the cost of missed face-to-face patient visits. Our current findings provide evidence that PCPs perceive that they have more time for patient visits when RNs are present because they have the opportunity for more face-to-face time with more patients.

It is also important to note that while RNs help to alleviate PCP workload and perform some PCP responsibilities, RNs also offer their own clinical nursing expertise vital to ensure optimal primary care delivery. Prior evidence illuminates that RN-perceived staffing adequacy is an effective way to measure and determine staffing levels based on patient needs (Choi & Staggs, 2014). Further, RNs are in a unique position to serve as a team member that acts as a cross functional liaison to integrate the work of other team members (Havens, Vasey, Gittell, & Lin, 2010). As reported in our results, the ability of the RN to shift between clinical and administrative tasks, such as administering a medication and then providing individualized patient education, as well as performing patient care coordination, can greatly alleviate some of the primary care demand for high quality care needed to achieve best patient outcomes. Based on these findings, we recommend that primary care organizations involve RNs to determine adequate staffing levels, individualize nursing roles that are clearly defined and use RN clinical expertise to the full extent of RN education and training.

There are limitations to this study. While the sample size was adequate for qualitative designs, PCPs outside of the study may have different perspectives. Future research that investigates RN perspectives, patient outcomes, and across a wider geographic range, are recommended to fully understand how to optimally incorporate RNs into primary care. This may include an investigation of longitudinal cost of various primary care team member designs, team productivity, and quality of care outcomes.

Conclusion

This study presents PCP perspectives about increased RN staffing in primary care. RNs are peceived to improve quality, safety, and continuity of care. When RNs are responsible for patient follow-up, PCPs perceive that acute exacerbations of illness are prevented, and that PCPs have more time freed up for additional patient encounters and administrative tasks. RN-led care can be enabled with the use of standing orders that in turn increases RN autonomy. Delegating RNs to the roles of care coordinators and to follow up with the patient after the PCP-patient encounter contributes to the individualization of patient care needs yielding a higher quality of care. Our findings suggest that PCPs perceive RNs to be an integral component of interprofessional primary care teams and whose expertise is needed to meet the care management demands in primary care. An increase in RN staffing is perceived by PCPs to help transform primary care through high quality nursing practice that increases patient safety, reduces the omission of important care management tasks, and ensures patient-centered primary care. Future research that examines various team designs that include RNs should be investigated to determine the impact on cost, practice and patient outcomes.

Table 2.

PCP perspectives of increased RN staffing in primary care

Theme	Examples of Related Codes
How RNs are integrated into primary care teams	“Team Based Driver” Shared ownership of patients “Boundary spanners” Team liaison “Discharge” RN Patient triage Point of Care testing Chronic disease management Immunizations
Improved quality, safety, and continuity of care with increased RN staffing	Individualized patient care plans Coordination of necessary patient resources (e.g. transportation) Orchestrating referrals Prevent omission of care Support continuity of care Monitoring care management guideline adherence Reduced hospital readmissions
Alleviation of PCP workload	PCP time “freed up” for other responsibilities Increased evidence-based practice Timelier diagnostic and laboratory results follow-up with patient