The Next Frontier for Nurses: Improving Quality and Safety in Primary Care

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THE most common career path for entry into the nursing profession is familiar and well-trod: go to college, get an associate degree or a bachelor of science in nursing, and then go to work in a hospital. This is a comfortable model that we've been using for 60 years. Many of you followed this path or something similar to it to begin your professional careers. Unfortunately, this paradigm is incomplete, given the demands of today's evolving health care system and the complexity of patient care.
There remains significant need for nurses providing acute care in hospital settings. But the traditional model overlooks the growing importance of having nurses at the front lines of care delivery in primary care settings. Nurses' role in advancing quality and protecting the safety of patients in primary care settings is too important to consign to an afterthought.
The association between nurse staffing levels in hospitals and the quality of acute care is widely accepted.1 There is, admittedly, less quantitative evidence about the direct connection between nurses and ambulatory quality and safety. But this is an area of great interest for us at the Agency for Healthcare Research and Quality (AHRQ). As the nation's lead federal agency for patient safety, AHRQ is highly motivated to improve safety and quality in health care wherever that care is provided. Increasingly, that place is the ambulatory setting.
Nurse practitioners (NPs) play a central role in ensuring the safety and quality of ambulatory care. The role of the NP is well established and defined. Today, there are more than 234 000 NPs licensed in the United States, with approximately 23 000 newly minted graduates emerging every year ready to join their ranks.2 NPs can examine patients, diagnose illnesses, prescribe medication, and provide treatments. In short, NPs are equipped to provide a broad range of primary care services and lead practice improvement efforts focused on quality and safety.
In contrast to NPs, the role of registered nurses (RNs) in primary care settings is less defined. However, as primary care moves to team-based practice models to meet the needs of Accountable Care Organizations and the Quality Payment Program, RNs are well positioned to take on leading roles and new responsibilities.3 Evolving RN primary care roles, especially in high-needs patients, include those of care coordinator, health coach, or health educator; furthermore, RNs can take a leadership role in the development of an integrated, dynamic, person-centric care plan and make home visits.4
There are barriers, however. NPs' scope of practice is limited in 27 states, and reimbursement of RNs for new models of team-based primary care is lacking. Overall, three-fifths of nurses work in hospitals, whereas only 10% of nurses work in primary or home care settings.5 The disconnect between the capabilities of nurses and the opportunities available to them is striking.
Everything about the way health care is delivered to patients is changing. Many of these changes have been driven by federal legislation, and future developments may have an additional or even greater impact. No matter what happens, we can and should prepare for a future in which we work to help make primary care practice safer and more efficient. This requires a thoughtful analysis of what tools we have (and what we lack) and what is the best and most effective use of limited resources to accomplish optimal outcomes for patients.
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