The Perspectives of Nurse Practitioners and Physicians on Increasing the Number of Registered Nurses in Primary Care

Allison A. Norful; Jennifer C. Dillon; Siqin Ye; Lusine Poghosyan


Nurs Econ. 2018;36(4):182-188. 

In This Article

Abstract and Introduction


AS MORE PATIENTS ARE LIVING with chronic disease, which is expected to reach 157 million Americans by 2020, it is crucial to ensure 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 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 sin gle-handedly (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 interprofessional primary care teams that consist of healthcare 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 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 between RN understaffing levels and suboptimal patient outcomes 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 hospitals 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 Nursing (AAACN) 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 (AAACN, 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 was to elicit PCP perspectives about 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.