Integrating Nursing into Primary Care: Issue Brief

Background

Chronic disease management accounts for up to 70% of healthcare expenditures in Canada, with the majority of these demands being placed on primary care initiatives ​⁷​. Nationally and internationally, attention has been given to the need to transform health systems to better meet the increasing needs of populations, communities, and individuals ​²​. This shift has included increasing calls for improving collaboration and establishing team-based care models in primary care settings ​²​. Primary care represents the first entry point into the healthcare system, whereby nurses of all designations hold the potential to promote comprehensive and timely delivery of healthcare ​³​. This is particularly true given nurses’ competence in health promotion, preventative screening, chronic and communicable disease management, and acute episodic care ​^2,8​, offering significant opportunities for nurses to contribute to improved patient outcomes, satisfaction and cost-effectiveness.  

With ongoing calls for action to improve access to primary care, the Ministry of Health of British Columbia (BC) has committed to working in collaboration with the Association of Nurses and Nurse Practitioners of British Columbia (NNPBC) to enable the integration of nursing roles in primary care networks and to ensure that nurses have the professional practice supports they need to deliver safe, quality nursing care to British Columbians. This partnership focuses on RNs and LPNs working in primary care through the BC Nurse in Practice Program.  

• LPNs are autonomous, self-regulated professionals with a diploma degree who care for individuals with stable and predictable conditions.  

• RNs are autonomous, self-regulated healthcare professionals with a baccalaureate degree and have a wider scope of practice that enables the provision of care to individuals with complex needs and those experiencing unpredictable health challenges ​⁷​. Additionally, some RNs hold Certified Practice, an expanded scope of practice that enables the autonomous diagnosis and management of certain medical conditions. 

Issue  

Despite nurses’ disciplinary and professional alignment with primary care initiatives and patient population needs, health systems in Canada have been late in integrating the full breadth of nursing designations into primary care practice settings. Although Nurse Practitioners (NP) hold a key role in primary care initiatives, the level of integration of Registered Nurses (RN) and Licensed Practical Nurses (LPN) remains a challenge, creating missed opportunities to improve population health. This delay in integrating the full complement of nursing designations is partly due to the lack of understanding of the role, scope, and health impacts of nurses within this area. For example, some studies report that in the absence of clear job descriptions, up to 40% of RNs lacked role clarity, with many reporting that they practise outside of their scope of practice. ​¹​ Furthermore, the degree of trust among other primary care providers impacts the extent to which nurses’ roles and scope are optimized in primary care settings. ​^4,5​ 

Structural barriers also impact the uptake of nursing roles in primary care. ​^2–4​ The literature suggests that in the absence of appropriate administrative staff, RNs could spend up to 55% of their time completing clerical work such as billing, filing, booking appointments, answering the phone and restocking equipment. ​¹ Lastly, funding models such as fee-for-service also serve as a barrier, as remuneration often requires that the primary care provider sees the patient, impacting the extent to which primary care providers refer patients to nursing services. ​^4,9​ 

Purpose 

To support the contribution of nursing care in primary care initiatives, policymakers and healthcare administrators must understand the current evidence that supports the integration and optimization of nursing roles in primary care. Drawing from national and international literature, the following brief clarifies the competencies, professional responsibilities and roles of nurses in these settings. It highlights their contributions to patient outcomes, health promotion, and chronic and communicable disease management and identifies facilitators for integrating nurses into primary care.  

Notably, the literature reviewed focused primarily on the RN role in primary care settings; however, the evidence supports the development of key policy recommendations for policymakers and healthcare administrators that support both RN and LPN integration into these settings to transform and improve primary care services for British Columbians.  

Methodology  

A preliminary search was completed using Google Scholar to identify relevant literature (see Appendix A in the linked PDF). Eight relevant articles were retrieved, and the full text of each article was read to identify potential keyword searches. From here, a final search strategy was developed. A review of the literature was undertaken in March and April 2024 using two databases, Google Scholar and the Cumulative Index for Nursing and Allied Health Literature (see Appendix A in the linked PDF).  

Articles were included if they focused on the LPN and/or RN role in primary care and provided a discussion on the implications of the nursing role concerning patient outcomes, access to primary care, or implications of physician practice. Articles that solely focused on the role of the nurse practitioners, were exclusive to virtual or telehealth care, or were focused on the development of education to support RN or LPN integration into primary care were excluded. No date limitations were set as the intention was to maximize results pertaining to the topic of interest. A total of 334 articles were screened, and 16 articles were retrieved, including the initial nine from Google Scholar and seven from CINHAL, 13 of which were included in this brief.  

Evidence review 

The contributions of RNs and LPNs in primary care can be understood by exploring their a) professional competencies, b) roles and responsibilities across care contexts, and c) procedural tasks to illustrate the knowledge, skills, competencies, and contributions that RNs and LPNs can bring into the delivery of primary care services.  

Competencies  

Canadian nurse researchers have developed 47 competencies for RN practice in primary care mapped across six domains of practice: professionalism, clinical practice, communication, collaboration and partnership, quality assurance, evaluation and research, and leadership ​¹⁰​. These competencies highlight the breadth and depth of competence that RNs can bring to the delivery of primary care services (see Appendix B in the linked PDF).  

Roles and responsibilities  

Organizations such as the Canadian Nurses Association ​¹¹​ have also developed sample role descriptions through a Primary Care Toolkit which includes key roles and responsibilities for the RN working in primary care. These key roles and responsibilities – conducting comprehensive health assessments, providing healthcare management and therapeutic interventions, delivering health education, supporting health promotion and illness prevention, addressing injury and complications, and understanding of professional role and responsibility – offer significant value to primary care service delivery.  

Key roles and responsibilities include: 

Health Assessments:  

• Obtains comprehensive health histories,  
• Conducts focused physical assessments and evaluations,  
• Reviews medications, intolerances, and allergies,  
• Assesses the availability of health coverage,  
• Identifies potential diagnostic and screening needs, and  
• Applies clinical best practice guidelines to guide decision-making regarding screening and monitoring requirements 

Healthcare Management and Therapeutic Interventions: 

• Development of interdisciplinary care plans. 
• Discusses treatment options and promotes informed decision-making. 
• Sets up supports as needed, such as transportation and medication delivery programs.  
• Determines the need for and initiating consultations. 
• Provides patient education regarding the results of diagnostics.  
• Provides pharmacotherapy teaching. 
• Prepares prescriptions for signing or facilitating ordering medications according to agency guidelines.  
• Chronic disease and medication management: Referrals to community services, wound care, suture and stable removal, specimen collection, International normalized ratio adjustments, injection medication including immunizations, dressing changes, wart treatment, foot care and assisting with procedures. 

Health Education: 

• Assess the need for health education, including current knowledge and health literacy.  
• Acquires, develops and evaluates teaching materials.  
• Employs educational strategies such as motivational interviewing to enhance health (e.g. Smoking cessation, physical activity and dietary patterns)  
• Engage patients in chronic disease education (e.g. COPD, hypertension, cardiac disease, cancer and chronic pain)  

Promotion and Prevention of Illness: 

• Conduct risk assessments in collaboration with the patient and members of the interdisciplinary team and develop appropriate care plans.  
• Assess immunization status and identify the need for immunizations.  
• Plans and participates in strategies to recall patients for monitoring and screening (e.g., diabetes monitoring, cervical screening, hypertension) and plans and coordinates screening for health issues. 
• Works as a navigator to ensure appropriate referrals and connections are implemented.  
• Maintains comprehensive health records.  

Professional Role and Responsibility:  

• Maintains evidence-based practices. 
• Leads or participates in research activities and conference presentations.  
• Participates in the development, implementation and maintenance of medical directives, policies, procedures and guidelines.  
• Completes all necessary documentation accurately. 
• Advances primary care nursing through professional development activities, including mentorship.  
• Demonstrates leadership in primary care activities and initiatives. ​¹¹​ 

It should be noted that although these responsibilities can help define the boundaries for nursing practice in primary care, these structures have only been developed for the RN, resulting in ongoing challenges for LPN role integration. The literature suggests that LPN and RN role clarity is challenging ​(4)​. Given that many primary care networks continue to have a disease-based model of care, RNs are often unable to work to their full scope of practice in injury prevention, health promotion and the social determinants of health. As a result, LPNs and RNs often perform similar role functions, if integrated at all ​⁴​. 

Roles and responsibilities across care contexts  

The roles and responsibilities of nurses in primary care vary and the literature illustrates a wide range of care contexts in which nurses work. For example, nurses in primary care work in various care areas including maternity, pediatrics, chronic and communicable disease screening and management, pharmaceutical management, primary and secondary chronic disease prevention, and patient education ​^1–3,5,8,12​. Another way to conceptualize the breadth and depth of nurses’ contributions in primary care is through their roles and responsibilities in providing care across the continuum from preventative care to episodic care and chronic disease management ​¹²​. Within these care contexts, RNs in primary care can take on the roles of relationship builders, care coordinators, outreach professionals, and programme facilitators at systems, organizational, and interpersonal levels ​(2)​. Other literature conceptualizes the RN role in primary care within the context of two roles – team RNs and RN case managers. Team RNs were found to provide myriad general functions, where RN case managers often provided more targeted and specific services for a particular subset of patients to facilitate comprehensive care coordination ​⁶​. Beyond the delivery of healthcare services, researchers have also found that RNs in some primary care settings are responsible for practice operations and serve administrative and coordinating functions ​^1,2​.  

Below are specific examples of roles and responsibilities that RNs carry out across care contexts, as evidenced in the literature.  

Pediatrics and Women’s Health:  

RN contributions to pediatrics in primary care settings include: newborn and infant developmental assessment, obesity assessments and interventions, audiometry assessment, lead screening, parental education (e.g. lactation, infant feeding, common conditions), support for children with cognitive delays and behavioural changes ​¹​. Evidence from the U.S. illustrates the value of implementing independent nurse visits and the contributions to pediatric populations ​⁶​. RNs have been found to contribute positively to women’s health through the delivery of pre-and post-natal exams, cervical PAP smears, and breast exams ​¹​. Maternal and child health is one of the most common areas where RNs provide targeted interventions ​²​. 

Chronic Disease Management and Patient Education:  

RNs in primary care settings often assess, monitor, and provide follow-up care to clients with chronic diseases – hypertension and diabetes being the most common ​¹​. For example, the assessment and monitoring practices of chronic diseases include monitoring changes in blood pressure and performing electrocardiograms, as well as adjusting insulin dosage, completing diabetic foot assessments, monitoring blood glucose levels, and completing screening for retinopathy ​¹​ Other roles and responsibilities discussed in the literature include the delivery of follow-up care for post-office and post-hospital visits, whereby RNs review consultations and diagnostic test results and develop additional treatment plans if needed ​¹​. Risk assessment and management is another component of the RN role in chronic disease management. For example, providing screening and assessments helps facilitate early interventions for chronic disease exacerbations, such as revising treatment regimens and developing primary care provider and specialty follow-up plans ​^1,3,12​.  

In the Canadian context, hypertension and diabetes are among the most common conditions managed by RNs working in primary care in Ontario ​⁷​. Similarly, RNs working in primary care networks in Alberta have been found to provide care for individuals with diabetes, obesity and dyslipidemia ​⁴​. Studies conducted in Atlantic Canada have also found that RNs carry out roles and responsibilities in chronic disease management for health concerns such as diabetes and smoking ​³​. Common roles and responsibilities include supporting risk-factor modification, promoting self-management, and providing patient counselling and education ​³​. One study of nurses working in primary care in Nova Scotia found that over 60% of nurses had patients referred to them by primary care providers for education in areas such as immunizations, diabetes, hypertension, and wound care ​⁵​.   

Disease Prevention and Episodic Illness Management:  

RN services in primary care were also noted to provide targeted interventions for primary and secondary disease prevention. For example, RN activities included assessment and education regarding obesity, monitoring food intake and body weight, implementation of treatment plans developed by dieticians, as well as conducting RN-led screening ​²​.  

In some regions in the US, RNs working in primary care clinics use pre-established order sets to provide episodic illness management, including telephone triaging, providing wellness counselling, and flagging key assessment indicators to guide the primary healthcare provider’s prioritization ​¹²​. Studies conducted in the US, Canada, and Australia have found that RNs are effective at managing patient concerns via telehealth medicine with regard to anticipating complications and providing educational guidance that reduces unnecessary use of acute care services ​¹​. One study of nurses working in primary care in Nova Scotia found that telephone triaging facilitated improved management for episodic illness exacerbations ​⁵​.  

Pharmaceutical Management: 

The evidence suggests that RNs practising in primary care are highly involved in the administration and management of oral and injectable medications ​¹​. Specifically, responsibilities include using existing protocols and practice guidelines to independently adjust medication dosages for chronic conditions, such as anti-diabetic agents and anticoagulant medications, such as warfarin. In some areas in the US, RNs assist primary care providers in common prescription renewal ​¹​. The literature has also found that a key contribution of RNs in high-functioning, team-based primary care practices is their capacity to participate in medication reconciliation, which provides an opportunity to collaborate with families and patients in a way that improves adherence to medication regimes associated with complex conditions ​¹²​. In 9 LEAP (learning from effective ambulatory practices) primary care clinics, RNs conducted independent visits, which encompassed medication titration according to protocols and being responsible for implementing patient-specific order sets developed by primary care providers to support the management of chronic illnesses ​⁶​. Furthermore, 13 of these clinics employed RN warfarin panel management, where RNs led warfarin clinics that included international normalized ratio testing and RN medication titration ​⁶​. 

Case Management, Care Coordination and Administration: 

Nurses in primary care settings play a vital role in referring patients to additional or specialty services ​¹​. In a Canadian study of nurses working in primary care, more than half of RNs (61%) were responsible for making independent decisions to refer patients to home care services, lactation specialists, social workers, dieticians and occupational therapists ​⁵​. RNs working in primary care settings can build and facilitate relationships within and outside of healthcare settings, which contributes to improved access to comprehensive care ​²​. Evidence from the US illustrates that RNs can contribute to transition management by identifying patients admitted to acute care, contacting them, and following up with them post-discharge ​⁶​. 

There is significant potential for RNs to contribute to primary care through supervisor and leadership roles. For example, this might involve providing supervision for LPNs and administrative staff and assuming leadership roles such as managing community-based teams, providing patient navigation and supporting continuity of care in the absence of primary care providers ​¹²​. Studies have found that RNs positively contribute to the management of clinical operations, facilitating improved clinic flow, identifying urgent same-day care visits, and after-hours scheduling needs ​¹²​. Other leadership and administrative roles might entail updating and maintaining policies and procedures and supporting research activities ​¹​.  

Procedural Tasks: 

Research has found that RNs engage in the following procedural tasks: vaccination, ear syringe irrigation, dressing changes, medication administration, removal of sutures, venipuncture, and first aid ​¹​, preparing and monitoring patients post-procedure, suture and staple removal, venipuncture, ear syringing, wound care, foot care, mini mental status examination, and vision screening ​⁵​.  

Outcomes 

In a systematic review exploring RN contributions to primary care, researchers found that RNs’ contributions to primary care result in a wide range of physiological disease control outcomes, patient experience outcomes, patient-reported outcomes, and health behaviour outcomes ​8​. For physiological disease control outcomes, studies have shown statistically significant reductions in HbA1c, BMI metrics, diastolic and mean arterial pressure and body weight for individuals with prediabetes in groups where RNs had been involved in care. Patient experience outcomes include improved satisfaction with care access, quality of support, and education provided. Patient-reported outcomes include changes in self-reported anxiety, depression, and pain, as well as improved quality of life ​⁸​. Lastly, health behaviour outcomes include increases in tobacco cessation or decreased use, improved physical activity levels and improved dietary practices ​⁸​. In addition to the findings of this systematic review, other literature reports similar outcomes associated with RN contribution to patient outcomes in primary care. These include:  

• Improved chronic wound healing (wound) ​¹​ 
• Increased patient education ​^1,3​  
• Improved chronic disease clinical outcomes, including improved blood pressure and A1C levels ​³​ 
• Increased screening and monitoring practices ​³​ 
• Reduced clerical stress as RNs act as a contact person for other health care providers ​¹​ 
• Increase access to primary care, including increased primary care visits, decreased emergency admissions, and shorter wait times ​^1,3​  
• In Spain, one-third of primary care objectives were supported by integrating RN responsibilities ​¹​ 

Facilitators 

While this evidence review illustrates the significant contributions that RNs bring to primary care delivery and patient outcomes, integration remains a challenge. Based on the literature, some facilitators to RN integration include: 

• The creation of standardized clinical practice guidelines to facilitate autonomous nursing practice in identifying abnormal findings, providing additional interventions, managing follow-up requirements, and enhancing patient safety ​¹​.  
• The development of standing orders for routine care provisions such as immunizations and vaccinations to ensure that RNs can carry out care activities without having a primary care provider present ​¹​. Standing orders were found to facilitate independent practice for RNs to conduct “preventive visits, manage visits, manage minor acute illnesses, and provide significant chronic illness care and management…” ​⁶​ ^p292 
• Access to routine screening programs and clinical practice guidelines to support chronic disease management, and an established method for flagging individuals with chronic diseases ​⁷​. 
• Joint appointments with nurses and other healthcare providers (e.g. social workers, dieticians, physiotherapists) to help foster collaboration and minimize duplication and fragmentation of care ​⁴​ 

Policy recommendations 

The literature regarding nurse integration into primary care is heavily focused on the RN role, creating ongoing challenges for LPN role optimization and integration within primary care networks. Despite this gap, many of the policy recommendations advanced apply to both RN and LPN integration. 

NNPBC offers the following recommendations for policymakers and healthcare administrators to consider to facilitate the integration of RNs and LPNs into primary care settings across BC.   

1. Employers should develop job descriptions in collaboration with RNs and LPNs to determine role responsibilities and maintain scope of practice ​¹​. 
2. To support role clarity and competencies, professional associations should draw from 47 competencies and the Canadian Nurses Association Primary Care Toolkit to inform the development of role-specific responsibilities and job descriptions ​^10,11​ 
3. To support new role integration, collaborative work between associations and employers is required to support increased individual-level accountability practices for nurses ​²​. 
4. Employers should develop standardized policies, procedures, and standing orders to maximize nurses’ professional autonomy and reduce primary care provider burden ​¹​. 
5. Employers must ensure sufficient administrative and clerical staff to maximize RN and LPN scope and role contributions ​^1,4​. 
6. Employers must ensure nurses have access to electronic medical records to support nurses in being able to obtain accurate information on patients and document according to standards of practice ​⁴​ 
7. Governments and professional associations should identify quality measures pertaining to care processes and patient outcomes to reflect RN and LPN contributions to primary care and evaluate effectiveness ​¹²​