May 6, 2013

This is a repost from Primary Care Progress and the first of our celebrating Nurses Week 2013.

photocredit: Primary Care Progress
photocredit: Primary Care Progress

The future of nursing in primary care
An interview with Virginia P. Tilden, Ph.D., R.N., F.A.A.N.

By Sonya Collins

Thank you for giving us an interview for National Nurses Week.

I’m very pleased to know that PCP is honoring National Nurses Week.  And I hope in the future that it’s joined by a Team-Based Care Week that is all about doing the right thing for patients.

I love that idea.  And how do you see the role of nurses in primary care evolving in the coming years? How do you see this role in ten years?

I see nurses in both staff and provider positions having a vital and expanding role and a responsibility for reinventing primary care now and in the years ahead.

In the staff role in traditional primary care practices, the RN typically does patient triage, telephone advice, and prescription management, sometimes including case management and chronic care management. Overall job satisfaction in this role typically is low, and burnout and turnover are high, such that medical assistants have tended to step into this staff role.

However, important reinvention of the RN staff role is happening now with exciting results. A recent ABIM Foundation study of innovative primary care practices found many RNs playing a different role. Care in these practices is typically team-based with RNs working at the top of their licenses as care coordinators, case managers, and systems specialists, resulting in much better patient care and higher morale for everyone, including physicians.

As providers, NPs carry patient case loads and/or manage specific services like heart failure or diabetes programs. They consult with and refer to physician colleagues as needed for any aspects of patient care that exceed their expertise and license. NPs are nationally certified and their education is at minimum a master’s degree – two years of graduate education. Increasingly, NPs extend their education to the doctor of nursing practice (DNP), which requires three to four years of graduate education and adds training in patient safety, quality improvement, and systems science. Additionally, nursing’s strengths in addressing the social determinants of health are well suited to the health needs addressed in the Affordable Care Act, including prevention, involvement of the family in care, and chronic illness management.

Ten years ahead, I see nurses seamlessly coordinating care, without some of the current byzantine barriers – many of our own making when it comes to education pathways. But before that, I see us stepping up and shouldering some of the responsibility for reinventing primary care, rather than waiting for physicians to do it.

What policy changes need to occur in order to make evolution of the nurse’s role possible?

First, it’s important to note that as for policy change, the train has left the station. We are well on our way to achieving some of the policy changes needed to allow nurses to take on greater responsibility.  Policies that affect education and practice have been under great scrutiny since the 2010 IOM report, The Future of Nursing: Leading Change, Advancing Health. Of the report’s many recommendations, two are particularly important to policy.

First, the nursing education system must reduce the barriers to education programs that hold students back from pursuing advanced degrees in nursing, particularly the unique challenges nurses with associates degrees face when they pursue higher degrees. There must be a dramatic increase in the number of nurses with a Bachelor of Science degree in nursing, as opposed to the associate degree in nursing, and in the number of nurses with doctorates, either the DNP or the PhD. A better-educated nursing workforce is needed for the expanded roles of the future. Further, more program curricula in the knowledge, skills, and attitudes essential to high-quality primary care must be developed on topics such as inpatient education, care coordination, care transitions, team-based care, quality improvement, leadership, and communication.

Second, the IOM recommends that nurses practice to the full extent of their education and training. But in many states, scope of practice laws prevent NPs from doing this. In about 18 states and the District of Columbia, NPs can diagnose, treat and prescribe without physician oversight; seven states require physician oversight of prescribing; and 25 states require “collaborative agreements” between NPs and MDs, meaning oversight of NPs’ diagnoses, treatment plans and prescribing.

While state laws are well intended, extensive and long-standing evidence shows that patient outcomes within areas of competence are equivalent with NP care and MD care. Further, a 2011 perspective piece in NEJM said, “There are no data to suggest that nurse practitioners in states that impose greater restrictions on their practice provide safer and better care or that the role of physicians in less restrictive states has changed or deteriorated.” In fact, restrictive scope-of-practice laws which prevent NPs from applying their training and certified competence result in out-migration of NPs, often robbing rural and underserved areas of access to care. In addition, they complicate NP reimbursement.

Financing nursing education and NP reimbursement are other areas for policy change and much is happening. As for education, CMS is directing some GME funds to hospital systems that train NPs. As for reimbursement, payment plans are shifting away from process toward outcomes, which will help address the discrepancies between MD and NP pay for comparable services. But this means NPs must be accountable for the same transparency of outcomes expected of physicians and should contribute to the national quality report cards available to the public so as to facilitate the public’s choice of provider and services.

What culture changes would you like to see take place?

The most important culture change is the growing expectation of team-based care. Teams maximize the complementary perspectives and skills of different professionals, thus addressing more of the patient’s needs and for more patients. But to get to this culture change, we need to focus on how we educate students and move away from solo and siloed training. It’s not enough anymore to be “solo good.” It’s assumed you will be a very good practitioner, but you also need to be “team great.”

Virginia P. Tilden, Ph.D., R.N., F.A.A.N., is dean and professor emerita at the University of Nebraska Medical Center College of Nursing and professor emerita at Oregon Health & Science University School of Nursing. She serves on PCP’s National Advisory Board.