Using Nurse-Sensitive Indicators to Assess the Impact of Primary Care RNs on Quality Ambulatory Patient Care

Rebecca Alley, MS, BSN, RN; Elizabeth Carreira, MSBA, BSN, RN, OCN, NE-BC, CPPS; Cynthia Wilson, MSN, BS, RN; Katelin Pickard, MSM, BSN, RN


Nurs Econ. 2021;39(4):200-207. 

In This Article

Abstract and Introduction


Creation of best practice care delivery models will influence registered nurses' participation as an equal partner in the interprofessional team. The Ambulatory Nursing Excellence Dashboard provides care teams meaningful, actionable data to inform care processes and drive improvements.


A shift in patient populations from acute to ambulatory care brought about a transformation in health care that only nurses can manage. As the incidence of chronic disease increases within the aging population and demands a focus on prevention in primary care, expanding capacity in this area is necessary (Buja et al., 2014). Strategies to care for aging populations with chronic health conditions now include a more comprehensive care plan before discharge, a system to help identify patients who require follow up, and implementation of a program to help monitor patients (American Hospital Association, 2007).

In an ambulatory care setting, the primary care physician (PCP) remains the healthcare leader for patients, including those with chronic diseases. Unfortunately, the number of PCPs continues to decrease. Of 8,116 primary care post-graduate training positions, only 42% are filled by graduates of U.S. medical schools (Schimpff, 2020). Physicians and advanced practice providers alone cannot meet the growing demand for primary care. Registered nurses (RNs) working to the full extent of their licenses will be needed at the front lines of care delivery.

Ricciardi (2018) noted that even though approximately 8,000 PCPs enter the workforce annually, the number of PCPs projected to retire will exceed that number by the early 2020s. In addition, new data reported by the Association of American Medical Colleges (2020) shows the projected shortfall in PCPs will be between 21,400 and 55,200 by 2033. While these trends are of great concern, they represent an opportunity for RNs to partner with physicians in a team-based approach.

As primary care continues to move to interprofessional team practice models, RNs are ideally positioned to take on leading roles and new responsibilities. Population health underscores an ever-increasing burden of chronic disease on the healthcare system and strives to eliminate barriers to preventive care of a vulnerable population by increasing access. Primary care team RNs often assume diverse roles – care coordinators, wellness coaches, patient educators, and advocates – especially for patients with chronic medical conditions. RNs will continue to foster greater development of integrated, patient-centric care plans in primary care teams. The Future of Nursing: Leading Change, Advancing Health determined healthcare transformation in all settings should be led by nurses (Institute of Medicine [IOM], 2010). The report also encouraged nurses to lead reforms to the healthcare system and improve data infrastructure.

Since the passage of the Affordable Care Act (Patient Protection and Affordable Care Act, 2010), substantial changes have accelerated in primary care. Flinter and coauthors (2017) reported findings suggesting the 20th century shift of RNs moving from primary care/community to acute care settings has reversed in the 21st century. The study's goals were to select and study high-performing, innovative primary care practices; identify developments in practice team composition, staff roles, and interprofessional teamwork; and disseminate promising advances. The study determined RN activities as value-added advances to patient care and the practice team (Flinter et al., 2017).

Increasing numbers of RNs are needed in ambulatory care settings to meet the demands of population health management in U.S. healthcare reform. RNs often find they can fully utilize their clinical skills and training and work with a higher level of independence in ambulatory care settings. Flinter and colleagues (2017) identified an urgent need for further research to develop knowledge, best practices, and policy for RNs in primary care, specifically measures to assess the impact of RN care managers on performance, satisfaction, and vitality.

The American Academy of Ambulatory Care Nursing (2017) documented the role of nurses in primary care to be "a complex, multi-faceted specialty that encompasses independent and collaborative practice…" (p. 4). Bodenheimer and coauthors (2015) defined the key domains of RN practice in primary care as "preventive care, chronic illness management, practice operations, care management, and transition care" (p. 288). The nursing profession's versatility and adaptive capacity allow nursing to expand scopes of practice and responsibilities. Although RNs have been identified as ideal members in the interprofessional team to drive reforms, their impact and utilization have not been widely measured to date (Start et al., 2018). Bodenheimer and coauthors (2015) described how several health systems use strategies to expand the RN role in primary care. RNs must recognize the importance of determining and measuring data that can be used as national benchmarks regarding their role to help gain a comparative perspective about their performance and quality care of patients.