Why is it important to rethink the role of the RN?

The role of registered nurses (RNs) in primary care has evolved a great deal in the last 50 years. Competition from hospitals for quality nurses and the corresponding rise in nurses’ compensation have caused many primary care practices to cut RN staff or find ways to maximize their value and productivity. RNs provide a unique set of clinical and management skills, that when used to their fullest potential, can enhance the primary care team and improve patient care. This topic focuses on the role of RNs as core members of a primary care team. Another important role for RNs is as specialized providers of care management for patients who have complex or chronic health problems. (Please see the Care Management topic if you are interested in this more specialized RN role.)

New Roles for RNs in Primary Care

The RN Role Reimagined: How Empowering RNs Can Improve Primary Care

How should the role of the RN change?

It is important to ensure that RNs are doing work that is uniquely suited to their training and expertise. In turn, other staff members need to take on some of the work that RNs have traditionally done, such as answering phones and phone triage, simple procedures, basic health education and health coaching, and patient outreach for preventive care.

Tasks that maximize the RN role include:

  • Complex care management.
  • Leadership of care teams/Team lead.
  • Shared visits with providers for well visits, preventive care visits, or visits with complex patients.
  • Running specialized care services, such as programs for obstetrics patients that provide additional support through extra consultation and support groups.
  • Providing independent visits and medication titration by protocol.

Given the many changes that RNs in primary care have undergone, it is understandable that many may be wary of change. But for their role in primary care to remain viable, RNs need to adapt and change along with the care team.

What do we gain by making these changes?

RNs bring a deep set of clinical skills and a desire to participate in direct patient care. It is imperative for both the fiscal health of primary care and RN job satisfaction to make the best use of their clinical skills on primary care teams. When providers and RNs work together, it allows a practice to offer longer, more comprehensive visits for chronically ill patients—while freeing up the provider to do tasks at the top of their license. 

The RN role in collaborative care visits - presentation slides

Webinar: the emerging role of nurses in primary care

  1. Assess what RNs are currently doing in your practice.

    The first step in changing the role RNs play on a primary care team is to assess the specific tasks that each member of the team is currently doing. This may expose tasks and functions that RNs can shift to other team members in order to free up their time for new tasks and responsibilities.

  2. Offload work that can be done by other team members.

    In order to work at the top of their license, it is critical for RNs to transfer tasks that the RNs might have traditionally performed to other staff members.

  3. Develop phone triage protocols that put other team members as the first point of contact.

    Traditionally RNs have been the primary contact for patients calling into primary care clinics with health-related questions. With improvements in technology, team-based communication, and evidenced-based guidelines, it should be possible to reduce the time RNs spend doing phone triage. 

  4. Provide RNs with tasks that maximize their clinical skills.

    As discussed above, there are a number of tasks that RNs can do as a member of their primary care team that maximize their clinical skills and training, and improve the efficiency of the primary care team.

  5. Hire the right person.

    As you shift the role of RNs in your clinic you may find you need more RNs or that there is a need to find individuals with a different skills set. LEAP sites often emphasized hiring individuals based on attitude rather than specific skill sets.

  6. Provide training and supervision.

    While RNs have generally had rigorous training, it may be important to offer your RN staff additional training on specific clinical and leadership skills. Topics might include motivational interviewing, disease-specific clinical skills, or facilitative leadership.

Webinar and power point presentations

  • Webinar and power point presentations

    New Roles for RNs in Primary Care

    LEAP Learning Community Webinar May 7, 2014. This webinar "New Roles for RNs in Primary Care" looks at the new and more robust roles for RNs, featuring speakers from 4 LEAP sites: St. Luke's Eastern Oregon Medical Associates, Harvard Vanguard Medical Associates, Martin's Point, and Community Health Centers, Inc.

  • Webinar and power point presentations

    The RN role in collaborative care visits - presentation slides

    These are slides that one LEAP site presented to their health system about the return on investment on having RNs functioning with a high level of autonomy. In this model, RNs conduct 1-hour Collaborative Care visits for patients with chronic diseases, during which the provider joins the RN for the last 15 minutes. They showed that collaborative care visits resulted in high quality care, increased care team member satisfaction, and reduced costs.

    Attribution:
  • Webinar and power point presentations

    Webinar: the emerging role of nurses in primary care

    Learn about the emerging roles for nurses in this webinar featuring LEAP sites. This is part of a great series of webinars on Advancing Team-based Care organized by Community Health Center, Inc. Slides are also available at http://weitzmaninstitute.org/NCA

Role featuresJob descriptions, career ladders and other HR materials

  • Role features

    The RN Role Reimagined: How Empowering RNs Can Improve Primary Care

    Learn strategjes for changing the RN role in primary care, in this comprehensive resource developed by the Center for Excellence in Primary Care (CEPC) and the California HealthCare Foundation (CHCF).

    Attribution:
  • Role features

    "Share the Care" Assessment of Team Roles and Tasks

    This is an example of a planning tool, to assess who is currently doing what tasks in your practice and then who should be doing each task, based on how we learned that LEAP sites define clear roles and responsibilities. Task distribution will vary from practice to practice, but the tool is in the discussion about roles that this worksheet can stimulate. Your practice may be able to redestribute tasks in a way that better fits your workforce and patient needs.

  • Role features

    Nursing roles in a Collaborative Care Model

    Learn about the various roles that RNs play in the team-based collaborative care model at one LEAP site, depicted in this diagram that describes team roles to patients. The Collaborative Care Nurse works with a PCP to manage chronic disease and provide health coaching. The RN Care Coordinator does care transitions and works with the most complex patients in the practice. Leadership developed new roles for nurses to best use their skills and training.

    Attribution:
  • Role features

    Registered Nurse—Primary Care Job Description

    Here is the job description of the team RN role at one LEAP site, Harvard Vanguard Medical Associates, reflecting the responsibilities and skills required to work at the top of the RN license. RNs have demonstrated positive clinical outcomes in patients at risk for cardiovascular disease following the implementation of a program that allowed RNs to titrate medications for hypertension, diabetes, and hyperlipidemia.

    Attribution:
  • Role features

    Staff Nurse Ambulatory (RN) Job Description

    Learn about the role of the Nurse care manager in diabetes management at one LEAP site, Cambridge Health Alliance–Union Square Family Health. Nurses provide increasing levels of education, support, and “touches” with patients based on the patient’s level of risk and control of A1c's.

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  • Role features

    Clinic Nurse Manager Role Description

    Read a description of the Care Team RN/Nurse care manager role at one LEAP site, West County Health Centers, reflecting the responsibilities and skills required to work at the top of the RN license. Nurse care managers have their own panel of patients who need more support and clinical monitoring to improve health outcomes.

    Attribution:
  • Role features

    Collaborative Care RN Job Description

    Learn about a new role for nurses in primary care that one LEAP site developed. The Collaborative Care Nurse is a team RN who helps patients manage stable chronic diseases and does some patient education and health coaching.

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Publications

  • Publications

    Collaborative Care: Partners in Chronic Disease

    See how one LEAP site redesigned its care model to empower RN roles for better results. Leadership prepared this presentation on collaborative care in which nurses are important partners with PCPs and patients in chronic disease care.

    Attribution:
  • Publications

    RN Flip Visit resources

    Learn how one LEAP site, Clinica Family Health Services, enables RNs to work to the top of their training and skills. In flip visits, an RN conducts acute visits with patients with a PCP. This document provides guidelines for implementing this innovative approach to team-based patient care that also improves access.

    Attribution:

WorkflowTemplates, flow sheets and mapping aids

  • Workflow

    Care Team Workflow: Provider, RN, MA, and Front Office

    This care team workflow, from LEAP site West County Health Centers, shows how the work is distributed across care team members. West County intentionally developed their care team model so that RNs could work to the top of their license and skillset. That involved distinguishing critical triage needing a nurse's advice from other types of calls, and sharing critical triage among the RNs in shifts.

    Attribution:
  • Workflow

    RN Protocol for short term follow-up

    There are some types of telephone follow-ups on a short-term patient need that are most appropriate for an RN to do, given the clinical expertise or discretion that is needed. West County Health Centers helps to make the distinction in this protocol, as a guideline for what needs an RN or what can be handled by another team member.

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  • Workflow

    RN Outreach for Cardiovascular Risk Reduction Enrolled patients

    See an example of protocol for titrating medications developed by one LEAP site, Harvard Vanguard Medical Associates, for RNs to use when needed while conducting outreach to patients at risk for cardiovascular disease.

    Attribution:

LEAP Learning ModuleOther helpful topics included in this website

Clinical protocolStanding orders, risk stratification forms and hospital transition protocols

  • Clinical protocol

    RN Diabetes Medication Titration Protocol

    See an example of standing orders for titrating diabetes medications developed by one LEAP site, Harvard Vanguard Medical Associates, for Team RNs to use, when needed, while conducting outreach to patients at risk for cardiovascular disease.

    Attribution:
  • Clinical protocol

    RN Hypertension Medication Titration Protocol

    See an example of standing orders for titrating hypertension medications developed by one LEAP site, Harvard Vanguard Medical Associates, for RNs to use, when needed, while conducting outreach to patients at risk for cardiovascular disease.

    Attribution:
  • Clinical protocol

    RN LDL Protocol

    See an example of standing orders for titrating hyperlipidemia medications developed by one LEAP site, Harvard Vanguard Medical Associates, for RNs to use, when needed, while conducting outreach to patients at risk for cardiovascular disease.

    Attribution:
  • Clinical protocol

    Nurse Protocols

    See a collection of nurse protocols that maximize clinical skills and streamline care for patients, from LEAP site Clinica Family Health Services. The first half are to guide treatment following positive lab results, and the section half are for conducting nurse-only visits.

    Attribution:

Staff trainingTutorials, training manuals, etc.

  • Staff training

    Nurse Orientation Checklist

    Here is a checklist used to guide RN orientation and training at one LEAP site, West County Health Centers, Inc. This reflects the leadership and clinical competencies that an RN must demonstrate after shadowing and training to fulfill the care ceam nurse/care manager role.

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