DescriptionPreparing Registered Nurses for Enhanced Roles in Primary Care
After reading the Macy Foundation Conference proceedings, write a summary of why you
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6 pts Intro is engaging and foreshadows what
This criterion is linked to a Learning Outcome the paper will include. The paper includes
– Introduction
why the Macy Foundation paper beneficial to
nursing curriculum
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4 pts APA format and references are correct,
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Writing – Style
June 15–18, 2016 | Atlanta, GA
Registered Nurses: Partners
in Transforming Primary Care
Recommendations from the Macy Foundation Conference on
Preparing Registered Nurses for Enhanced Roles in Primary Care
Primary care in the United States is in urgent
need of transformation. The current organization
and capacity of our primary care enterprise are
insufficient to meet the healthcare needs of the
public. The 2010 Affordable Care Act (ACA),
which emphasizes the importance of primary care,
has enabled millions more people to seek care at
a time when more than half of Americans have
at least one chronic condition and many have
multiple illnesses and complex healthcare needs—
trends that will continue as the population ages.
However, resources currently allocated to primary
care are inadequate. Strengthening the core of
primary care service delivery is key to achieving
the Triple Aim: improved patient care experiences,
better population health outcomes, and lower
healthcare costs.
These mounting pressures from external forces are
shifting primary care toward new practice models
staffed by high-functioning, interprofessional
teams. Teams can increase access to care; improve
the quality of care for chronic conditions; and
reduce burnout among primary care practitioners,
including physicians, physician assistants, and
nurse practitioners. But this team-focused culture
shift is nascent and, without enough appropriately
trained healthcare professionals, primary care
could falter under the increased demand.
Who can help alleviate the pressures on primary
care? A tremendous, available resource is the 3.7
million registered nurses (RNs)—who comprise
the largest licensed health profession in the nation.
RNs are the ideal team members to help expand
primary care capacity, yet they have been woefully
underutilized in primary care settings. Practices
that have deployed registered nurses in enhanced
roles have shown improved health outcomes,
reduced costs, and enhanced patient satisfaction.
Josiah Macy Jr. Foundation | 44 East 64th Street, New York, NY 10065 |
Registered nurses, appropriately prepared and
working to the full scope of their licensure, can
successfully implement and sustain patientcentered services for the aging and increasingly
complex primary care population. They can
increase access to care for all patients, and
also assist in the management of patients
with chronic diseases—such as diabetes,
hypertension, chronic obstructive pulmonary
disease, and substance abuse and mental
health conditions—who require more services.
They also can help improve transitional care,
as patients move between hospitals, other
care facilities, and home. Further, they can
help improve patient engagement, quality
scores, and team collaboration using health
assessments, patient education, motivational
interviewing, medication reconciliation, care
planning, and more. This can occur through
RNs following a panel of patients as well as
through nurse-led individual and group visits.
perhaps most importantly, many RNs are
not exposed consistently to the full range
of primary care content in the classroom or
through instructional clinical experiences,
which overwhelmingly focus on inpatient and
acute care. As a result, RNs may lack skills
and competencies essential to functioning
effectively in primary care.
While the large RN workforce has the potential
to help meet the 21st century demands facing
primary care, a number of barriers must be
overcome. First, many RNs currently working
in primary care spend much of their time
on patient triage, sorting out who needs to
be seen immediately and who can wait. This
is an important function, but primary care
practices need to balance RNs’ time between
traditional triage and the emerging chronic care
management, care coordination, and preventive
care. Second, some state laws limit utilizing
RNs to the full extent of their education and
training. Even when state law supports full
practice authority, healthcare organizations
sometimes restrict RNs from practicing to the
full extent of their licensure.
The conference generated actionable
recommendations around the potential for
RNs to help meet the urgent needs of primary
care. Participants at the two-and-a-half-day
working conference—held June 15–18, 2016
in Atlanta, Georgia—included more than 40
leaders in primary care, representing academic
nursing and medicine, healthcare delivery
organizations, professional nursing associations,
healthcare philanthropy, and more. Nursing
students also were at the table.
Third, much of the work that RNs and
other primary care team members currently
perform is not directly reimbursable under
the traditional fee-for-service payment model,
meaning that new payment models are
needed to facilitate the growth of primary
care teams that include RNs. Finally, and
The significance of these issues and their
relevance to the mission of the Josiah Macy
Jr. Foundation prompted the Foundation to
focus its annual conference on the topic of
Preparing Registered Nurses for Enhanced Roles
in Primary Care. The conference represented
the intersection of three themes of importance
to the Foundation in its efforts to help reform
health professions education: improving
primary care, preparing nurses for leadership
roles, and linking education reform and
healthcare delivery transformation.
“The forward momentum in primary care
means we are moving in the right direction,
toward higher value care that is focused on
improving the health of the public,” said Macy
Foundation President George Thibault, MD.
“But we have a long way to go. We simply
can’t meet the primary care needs of the nation
unless registered nurses are part of the solution,
and we must prepare them appropriately and
then use them for this role.”
Context for the Conference
Nursing has its roots in primary health care.
Florence Nightingale, widely recognized as the
19th century founder of modern nursing, said:
“Money would be better spent in maintaining
health in communities rather than building
hospitals to cure.” By the early 20th century,
registered nurses were serving as autonomous
primary care providers, particularly in urban
centers and rural communities where the needs
were greatest. In 1919, a nurse-run community
health center regarded the hospital as a “repair
shop, necessary only where preventive medicine
has failed.”
Nursing, at its core, has a history of
helping patients identify and improve their
psychosocial and health needs. Nursing
education, in contrast to other health
professions education programs, includes
a holistic approach to patients that is not
solely based on organ systems or body parts.
Nursing science includes an assessment of
personal and familial health within a social
and environmental context, not just a focus
on disease and treatments. This becomes even
more important as the role of primary care in
the U.S. health system expands to acknowledge
and address the role that social determinants of
health play in achieving improved health status.
By the mid-20th century, health care’s center of
gravity shifted from homes and communities to
hospitals, and the nursing profession followed
suit. Approximately, 60% of registered nurses
work in hospitals, and nursing schools focus
on the skills needed for inpatient hospital care,
with little attention paid to practice in primary
care settings. Yet the costs of hospital-based
care are too high and the health of Americans
lags behind other developed nations. Today,
the pendulum is swinging back toward
community-based primary care. Changes in
nursing education, regulations, and payment
are critical to support and accelerate this shift.
The Institute of Medicine’s Future of Nursing1
report, released in 2011, echoed these themes:
“[W]hile changes in the healthcare system
will have profound effects on all providers,
this will be undoubtedly true for nurses.
Traditional nursing competencies, such as
care management and coordination, patient
education, public health intervention, and
transitional care, are likely to dominate in a
reformed healthcare system as it inevitably
moves toward an emphasis on prevention and
management rather than acute [hospital] care.”
While significant progress has been made
on the Future of Nursing recommendations
concerning advanced practice nurses,
particularly nurse practitioners, comparatively
little attention has been paid to the report’s
implications for RNs. The American Academy
of Nursing approached the Macy Foundation
to raise the significance of this issue, and
the Foundation now hopes to reignite the
conversation on the enhanced role of registered
nurses in transforming primary care to meet
the needs of the nation.
Conference Discussion
To create a baseline from which to launch the
conference discussion, the Macy Foundation
commissioned four papers2 on topics related
to registered nurses and primary care practice.
Prior to the conference, participants read the
commissioned papers as well as other suggested
articles, and on the first day of the conference,
discussions centered on themes from these
The first paper, The Future of Primary Care:
Enhancing the Registered Nurse Role by
Conference Co-chair Thomas Bodenheimer,
MD, MPH, and his colleague, Laurie Bauer,
RN, MSPH, both of the University of
California, San Francisco, described how the
1 Institute of Medicine. 2011. The Future of Nursing: Leading Change,
Advancing Health. Washington, DC: The National Academies Press.
2 Papers commissioned for this conference will be published in the
full conference monograph in fall 2016.
transformation of primary care in the United
States is creating “favorable conditions” for
growth in the number of RNs in primary care,
particularly in larger practices and community
health centers.
The paper also elucidated the likely roles of
primary care RNs as focused around patients
with chronic disease; patients with complex
health needs and high healthcare costs; and
patients whose care must be coordinated across
many settings, including hospitals, skilled
nursing facilities, ambulatory practices, and
private homes. Barriers to more RNs working
in primary care include the scarcity of nurses
adequately prepared to perform primary care
functions and payers not reimbursing for work
performed by some members of the primary
care team, including RNs.
Registered Nurses in Primary Care: Strategies
that Support Practice at the Full Scope of
the Registered Nurse License was the second
commissioned paper. It was written by
Margaret Flinter, APRN, PhD, FAAN,
senior vice president and clinical director for
Community Health Center Inc. (CHCI);
Mary Blankson, APRN, DNP, chief nursing
officer for CHCI; and Maryjoan Ladden,
APRN, PhD, FAAN, senior program officer at
the Robert Wood Johnson Foundation. This
paper posits that achieving “better, safer, higher
quality care that is satisfying to both patients
and providers, and affordable to individuals
and society” will require us to “effectively use
every bit of human capital available in the
primary healthcare system,” and presents a
vision for the “blue sky” future of primary care
and the role of RNs.
In this future, instructional programs offered
by nursing schools, health systems, professional
organizations, and others will help existing
RNs transition their careers to other settings,
and will offer learners opportunities to
specialize in primary care, community health,
or public health nursing, including the option
to complete a residency or similar clinical
education program in community-based
settings. In this future, in which all patients are
served by primary care teams, registered nurses
will take on prevention and health promotion
activities, minor episodic and routine
chronic illness management, and complex
care management in conjunction with other
team members. They also will possess skills in
population management, quality improvement,
and team leadership; will provide counseling
and care services via telehealth; and will expand
the reach of primary care into the community.
The authors conclude by stating: “This
blue sky state requires much more than just
changing educational preparation. It requires
today’s leaders and providers to reorganize
today’s primary care practices and systems to
accommodate a truly collaborative model of
team-based primary care.”
The third paper commissioned for the
conference, Expanding the Role of Registered
Nurses in Primary Care: A Business Case
Analysis, was written and presented by Jack
Needleman, PhD, FAAN, professor and
chair of the department of health policy and
management at the University of California,
Los Angeles Fielding School of Public Health.
The author describes new roles for RNs that
achieve economic gains by engaging their
expertise and reducing demands on primary
care clinicians. These roles include RN covisits; RN-only visits using standing orders;
and increased responsibilities for RNs in care
coordination, telehealth, patient education, and
health coaching.
Through two case studies, the author describes
how primary care practices have financially
supported the expanded role of the RN. For
example, in fee-for-service settings, increases
in billable services can help pay for RNs in
these new roles, while in capitated settings,
additional RN-related costs can be offset
by reduced use of other services, such as
emergency department visits and hospital
readmissions. Additional research is needed
to examine the feasibility of these roles under
emerging value-based payment structures and
solidify the business case, but evidence suggests
that increased engagement of RNs in caring for
high-cost patients with chronic conditions will
pay for itself and improve care.
The fourth and final commissioned paper
discussed at the conference was Preparing
Nursing Students for Enhanced Roles in Primary
Care: The Current State of Pre-Licensure and RNto-BSN Education by Danuta Wojnar, PhD,
RN, FAAN, professor and associate dean for
undergraduate education at Seattle University
College of Nursing, and Ellen-Marie Whelan,
PhD, RN, CRNP, FAAN, chief population
health officer at the Center for Medicaid
and CHIP Services. The authors presented
results from their survey examining primary
care content in the curricula of the more
than 500 pre-licensure (entry-level associate,
baccalaureate, or master’s degree) and RN-toBSN education programs that responded to
the survey. Though the authors acknowledged
limitations regarding their findings, among
survey respondents, only about 20 programs
offered a robust primary care curriculum.
Findings from the survey focused on factors
that facilitate and inhibit the implementation
of primary care content in nursing curricula.
Some of the factors facilitating primary care’s
inclusion in nursing schools are recognition
of the emerging shift toward primary care;
visionary leadership and forward-thinking
faculty; increasing opportunities to learn
with other health professions students; and
mandates from state nursing commissions.
Factors inhibiting the inclusion of primary care
curricular content are lack of faculty buy-in
and RN faculty preceptors; logistical challenges
coordinating with community-based teaching
sites; students’ fear of not acquiring acute care
skills; and the perception that primary care is
not considered a significant content area on the
National Council Licensure Examination for
During conference discussions, participants
agreed that registered nurses are well suited
to both generalized and specialized roles
within primary care. Examples of generalized
roles include managing the care of panels of
patients with chronic diseases, working with
interprofessional teams to improve the care of
patients with complex healthcare needs, and
managing transitional care for patients between
inpatient facilities, ambulatory care, and home
care. Registered nurses who are experts in
diabetes, heart failure, asthma, or behavioral
health, or who are focused on populations
such as children or women, might perform
specialized roles. A body of evidence regarding
the contributions of nurses in such roles has
demonstrated improved health outcomes and
reduced costs.
As discussions progressed, conferees also agreed
that preparing registered nurses to serve in
expanded roles will require exposing learners
to all types of nursing, including caring for
patients across their lifespans and across all
kinds of settings, from hospitals to community
health centers and schools, from private homes
to homeless shelters. While RNs should not be
limited to acute [hospital] care, neither should
they be limited to primary care. Instead, they
should be encouraged to explore a variety of
practice options to determine the best fit for
their personal and professional needs and
interests. Expanding educational options for
nursing students, including the development
of interprofessional, collaborative practice
opportunities in a variety of community-based
clinical settings, will require strong partnerships
between leaders of academia and clinical practice.
Conferees also discussed how RNs can help
address two other concerns that permeate
many healthcare organizations: insufficient
attention to eliminating persistent disparities in
care, which harm vulnerable populations; and
overemphasis on acute care while minimizing
the social determinants of health. RNs trained
in culturally responsive care, including
developing the knowledge and skills to
recognize and address implicit and explicit bias
and racism, will be better prepared to care for
diverse patients and address population health.
Essential to all of this, the conferees agreed, is
changing the culture of health care in general,
and nursing in particular, to place more value
on primary care as a career choice. Nursing
leaders within both academia and practice
environments must assume responsibility for
this culture change. In concert, primary care
practitioners must embrace enhanced roles
for RNs in primary care. The Macy conferees
agreed that enhancing the role of RNs to serve
as members of primary care teams will not
only improve patient care, but also help reduce
burnout and increase job satisfaction among all
team members. Further, if primary care hopes
to solve its capacity problem in caring for the
21st century population, primary care practices
will need to attract RNs by empowering them
to enjoy professionally rewarding jobs—caring
for patients, promoting health, preventing
illness, and addressing population health.
“The forward momentum in primary
care means we are moving in the
right direction, toward higher value
care that is focused on improving the
health of the public, but we have a
long way to go. We simply can’t meet
the primary care needs of the nation
unless registered nurses are part of the
solution, and we must prepare them
appropriately and then use them for
this role.” — George Thibault
Conference Themes
I: Changing the Healthcare Culture
The second day of the conference built upon
the discussion themes that emerged during
the first day, and conferees broke into groups
to begin crafting recommendations in the
following areas.
II: Transforming the Practice Environment
III: Educating Nursing Students in Primary Care
IV: Supporting the Primary Care Career
Development of RNs
V: Developing Primary Care Expertise
in Nursing School Faculty
VI: Increasing Opportunities for
Interprofessional Education
Conference Recommendations
Over the course of the second day, specific recommendations and supporting
or sub-recommendations were drafted in small groups and debated during
plenary sessions. On the third day, the draft recommendations were reviewed
and refined—a process that continued via phone and email following
the conference. As a group, the conferees felt strongly that the following
recommendations were urgently needed and possible to achieve.
1. Leaders of nursing schools, primary care practices, and health systems
should actively facilitate culture change that elevates primary care in RN
education and practice.
2. Primary care practices should redesign their care models to utilize the
skills and expertise of RNs in meeting the healthcare needs of patients—
and payers and regulators should facilitate this redesign.
Nursing school leaders and faculty should elevate primary care content
in the education of pre-licensure and RN-to-BSN nursing students.
Leaders of primary care practices and health systems should facilitate
lifelong education and professional development opportunities in primary
care and support practicing RNs in pursuing careers in primary care.
Academia and healthcare organizations should partner to support and
prepare nursing faculty to educate pre-licensure and RN-to-BSN students
in primary care knowledge, skills, and perspective.
Leaders and faculty in nursing education and continuing education
programs should include interprofessional education and teamwork
in primary care nursing curricula.
Recommendation I
Changing the Healthcare Culture.
Leaders of nursing schools, primary care
practices, and health systems should
actively facilitate culture change that
elevates primary care in RN education
and practice.
Changes in educational priorities and in the
structure of primary care practices will not
happen without leadership from educational
institutions, primary care practices, and
professional organizations. Their incentive
to take on this leadership role comes from
evidence that these changes will result in better
patient care, improved utilization of resources,
and enhanced professional satisfaction. The
necessary policy and payment reforms and
broad community support will also require
leadership advocacy. In addition, while there is
evidence of the value of RNs in primary care
practices, building a strong business case for
their use will accelerate the pace of change in
both education and practice.
Actionable Recommendations
1. Leaders of all healthcare organizations
should support a culture change that
reimagines primary care and the enhanced
role of RNs. This culture change should
maintain academic rigor around the
biomedical model while increasing
the emphasis on the family, social,
environmental contexts of health and the
importance of interprofessional teamwork
in achieving better patient outcomes and
greater professional satisfaction.
2. Leaders of nursing schools and practice
sites should advocate and allocate resources
for a re-balancing of nursing education
to give greater priority to the teaching
of primary care knowledge, skills, and
attributes to pre-licensure nursing students,
to RNs considering transitioning to
primary care careers, and to the continuing
professional development of primary
care RNs. This will mean providing
more primary care clinical opportunities
for all pre-licensure nursing students,
professional development opportunities for
RNs in primary care who want to take on
enhanced roles, and continuing education
for practicing RNs contemplating a move
into primary care.
3. Leaders of both educational and healthcare
delivery systems should promote the
academic-community partnerships
that will be necessary to achieve the rebalancing of education and the higher
visibility of primary care. Nurses should
be in meaningful leadership roles in these
partnerships, and the career development
of nurses in these partnerships should be
supported. These academic-community
partnerships should also include patient,
family, and community representation.
4. Leaders of both educational and healthcare
delivery systems should work with policy
makers, payers, government agencies,
large employers, and community leaders
to advocate for the changes necessary to
support the work outlined in this report.
5. Leaders of all stakeholder organizations
should help disseminate these
recommendations, working with the
American Academy of Nursing and the
Josiah Macy Jr. Foundation.
Recommendation II
Transforming the Practice
Environment. Primary care practices
should redesign their care models to
utilize the skills and expertise of RNs
in meeting the healthcare needs of
patients—and payers and regulators
should facilitate this redesign.
Patient quality outcomes and the abilities of
practices to build capacity can be improved
using enhanced RN roles, but government and
private payers must provide financial support
for building primary care capacity. In addition,
the practice environment must value enhanced
RN roles and design care delivery and payment
models to make best use of RNs’ skills and
competencies. Doing so will improve access,
outcomes, care coordination, and satisfaction.
Some best practices in the optimal deployment
of RNs in primary care already exist.
Exemplary primary care practices3 are using
RNs to begin the appointments, take histories,
engage patients, and set the stage for long-term
relationships—with a primary care practitioner
(PCP) coming in near the end of a visit to
perform medical management. Others are
utilizing co-visits with RNs and PCPs working
side-by-side in the patient encounter. In these
practices, an RN takes the lead role in patient
engagement, education, and activation, and
uses data to inform practice. The nurse also
may take the lead on pre-visit planning and
follow up after the visit, in collaboration with
the PCP, as well in transitional care and disease
management. In most documented cases,
relying on RNs in these ways has enabled
primary care practices to increase their volume
and revenues to the extent that, at a minimum,
the RN’s salary is offset.
3 Examples of exemplary primary care practices will be included in
the full conference monograph in fall 2016.
Actionable Recommendations
1. Primary care practices should evaluate
the skill mix of current team members
to ensure that their contributions are
optimized, and either hire RNs into
enhanced roles or reconfigure the roles of
those already on the team. The RN roles
should include care management and
coordination for aging and chronically
ill patients and those with increasingly
complex health needs; promoting health
and improving patients’ self-management
of prevention and behavioral health
issues; and placing greater emphasis on
transitional care, prevention, and wellness.
Practices should optimize the potential of
RNs, allowing them to spend ample faceto-face time with patients.
2. Health systems and primary care practices
should support the transformation from
practitioner-dominated care models to
team-based care models (“I to we”), with
RNs leading the primary care team when
appropriate given their expertise.
3. Payers should develop alternative payment
models—such as shared savings for
reducing expensive hospital admissions,
re-admissions, and emergency department
visits—so that the work of all primary care
team members, including RNs, adds value
rather than simply increases expenses. In
fee-for-service systems, specific RN-visit
types, such as Medicare wellness visits and
care coordination, should be reimbursed at
a higher level. RNs should be encouraged
to acquire a National Practitioner Identifier
(through the National Plan and Provider
Enumeration System) for both payment
and tracking purposes.
4. Nursing, primary care, and health
services researchers as well as primary care
administrators and chief financial officers
should develop the business case for
enhanced RN roles in primary care, with an
emphasis on their impact on quality; costs;
patient, family, and team member and staff
satisfaction; and their contributions to
addressing social determinants of health in
primary care settings. The evidence-based
Ambulatory Nurse-Sensitive Indicators
provides a much-needed tool to assist in
quantifying the value of RNs in primary
5. Healthcare systems, professional
organizations, states, and other regulatory
entities should identify barriers, real and
perceived, that limit or impede enhanced
roles in primary care for registered nurses.
Of particular importance are strategies for
reducing barriers presented by outdated
state practice acts that may limit RNs’
abilities to utilize their skills to the fullest
extent. State medical and nursing boards
and health system leaders should rely on
research that supports enhanced roles in
primary care for RNs, and they should
facilitate the adoption of evidence-based
guidelines and standing orders that
empower RNs to carry out these roles.
Recommendation III
Educating Nursing Students in Primary
Care. Nursing school leaders and faculty
should elevate primary care content in
the education of pre-licensure and RNto-BSN nursing students.
A multi-pronged approach that spans
classroom and clinical instruction is critical to
elevating primary care in nursing education.
Interventions include developing the pipeline
of students interested in primary care, rebalancing curricula between acute and primary
care instruction, and supporting graduates
in seeking RN roles in primary care. The rebalancing of curricula to incorporate primary
care content should be informed by adult
learning theory and educational scholarship.
These efforts will create a movement to build a
critical mass of RNs in primary care.
Actionable Recommendations
1. Nursing schools should work with the
communities they serve to develop a
pipeline of diverse students to meet the
needs of diverse patient populations.
Admissions criteria should be broadened to
identify candidates with particular interest
in and aptitude for primary care and
community service.
2. Nursing faculty must broaden and deepen
the primary care focus in the curriculum.
Doing so includes enriching content on
topics such as wellness, health promotion,
and disease prevention; population health
and risk stratification; motivational
interviewing and health coaching; health
equity; leadership, cost of care, delivery
models and systems innovations; care
coordination and care transitions; chronic
care and complex care management with
associated behavioral health concerns;
longitudinal care throughout the lifespan;
culture change and primary care practice
transformation; informatics and data
analytics; and telehealth and virtual
delivery models.
3. Schools of nursing must reach out
to primary care practices to develop
innovative arrangements for meaningful
clinical experiences for nursing students.
Accomplishing this will require that
schools create an inventory of primary care
practices, partner with them to develop
enhanced clinical experiences that can
include longitudinal opportunities for
students to serve the same individual
and family across settings, and adapt the
designated education unit concept in highperforming primary care sites.
4. Nursing faculty must provide opportunities
for students to have exposure to primary
care outside of the curricular experiences.
This exposure could include informing
students of the opportunities to delve more
deeply into issues in primary care through
working with organizations that promote
primary care, such as Primary Care
5. Nursing faculty should establish a strong
evaluation and research component
to improve on curricular changes and
identify best practices in preparing prelicensure and RN-to-BSN students for
enhanced roles in primary care. This
component could include examining the
impact of curricular changes on licensure
performance and career choices.
Recommendation IV
Supporting the Primary Care Career
Development of RNs. Leaders of
primary care practices and health
systems should facilitate lifelong
education and professional development
opportunities in primary care and
support practicing RNs in pursuing
careers in primary care.
Registered nurses working in primary care
practices or interested in transitioning into
primary care will need to strengthen or build
primary care knowledge and competencies in
areas that include chronic disease management,
care coordination, care transitions, prevention
and wellness, interprofessional teamwork, and
triaging. This skills acquisition will require
a learning system designed to assure that
the most recent knowledge for innovation,
evidence, system design, leadership, and
technology within primary care settings
is available and accessible to practicing
RNs. Educational modalities should be
varied, flexible, and promote development
of a diverse primary care RN workforce,
including opportunities for academic-practice
partnerships, residency programs, and
engagement in the redesign of primary care
Actionable Recommendations
1. Schools of nursing, health systems, and
professional organizations should create
opportunities for lifelong education and
professional development in primary care
for RNs, including nurse managers and
executives. Potential partners who can
help develop learning modules include
professional nurses associations as well
as national organizations focused on
healthcare transformation.
2. The American Nurses Credentialing Center
(ANCC) should establish a Magnet®-type
recognition program for primary care
practices, or incorporate a primary care
focus into the existing Magnet® program.
This would encourage primary care systems
to create practice environments known
for their excellence in nursing practice
and high-quality care. The ANCC should
convene leaders within professional nursing
associations to develop an action plan.
3. Academic and practice leaders should
develop academic-practice partnerships
across primary care settings and schools
of nursing to create residency programs in
primary care; enhance RN development;
co-design curricula and toolkits for
implementing educational programs;
and disseminate co-designed curricula to
organizations supporting primary care
transformation, such as health plans,
foundations, and consultant agencies, as
well as entities that provide continuing
nursing education.
4. Primary care practices should establish
opportunities to engage registered nurses
in the redesign of primary care with foci on
full RN practice authority, leadership, and
interprofessional practice.
5. Primary care practices and organizations
involved in training healthcare professionals
should provide staff development and
continuing education on enhanced RN
roles at the practice level, prioritizing RNled contributions to the specific needs of
the community served by the practice and
reflecting the culture, language, and values
of the community.
Recommendation V
Developing Primary Care Expertise in
Nursing School Faculty. Academia and
healthcare organizations should partner
to support and prepare nursing faculty
to educate pre-licensure and RN-to-BSN
students in primary care knowledge,
skills, and perspective.
Although some nursing faculty teach primary
care content in undergraduate programs, many
are more comfortable teaching acute, inpatient
hospital content in classrooms and clinical
settings. To re-balance nursing education
toward a greater primary care orientation, there
is a need for considerable faculty development
in the areas of primary care nursing knowledge,
skills, and functions. Academia and ambulatory
practices should work together in this endeavor.
A primary care perspective not only looks at an
acute inpatient episode in a patient’s life, but
also concerns itself with the entire trajectory
of a patient’s illness throughout the lifespan.
Moreover, while nursing care in acute settings
has focused on RNs implementing the orders
of practitioners (physicians, nurse practitioners,
or physician assistants), RNs in ambulatory
practice may make autonomous patient care
decisions within their scope of practice and
under standardized protocols.
Actionable Recommendations
1. Deans, other leaders of nursing
education, and faculty should utilize an
interprofessional model of RN faculty
development. Faculty who achieve
competence in primary care practice should
be recognized and rewarded for their
broadened knowledge, expertise, and skills.
2. Health systems and health insurers should
help fund faculty development, including
residencies and fellowships in primary care
nursing, as they may benefit financially
from the enhanced RN primary care roles.
Further, schools of nursing should develop
innovative partnerships with primary care
practices to help them recruit faculty and
develop instructional materials and other
educational resources on the primary care
nursing paradigm.
3. Nurses actively working as care
coordinators, chronic care managers,
and other enhanced roles in primary care
should have joint faculty appointments to
teach both didactic and clinical primary
care competencies. Nursing faculty
should spend time working in primary
care practices to enhance their own skills
and close the gap between education and
4. Nursing faculty should model an RN
culture of equal partnership with physicians
and other team members, such that RNs
become comfortable caring for patients
autonomously under standardized
protocols as authorized by state nursing
boards. Faculty should educate nurses to
care for patients not only during an acute
episode of illness but also throughout
their lifespan and across acute care,
primary care, and home settings, paying
attention to socioeconomic, cultural, and
environmental factors impacting the health
of the population.
5. Partnerships should be developed between
nursing schools, other health professions
schools, and health systems to further
the integration of RN education and
interprofessional education with primary
care clinical practice. Partnerships may be
contractual, specifying the responsibilities
of each party, or involve a health system
partnering with a nursing school to create
the strongest possible integration between
RN education and practice.
Recommendation VI
Increasing Opportunities for
Interprofessional Education. Leaders
and faculty in nursing education and
continuing education programs should
include interprofessional education
and teamwork in primary care nursing
Interprofessional teams are key to successfully
transforming primary care to meet the
healthcare needs of the public. Thus,
opportunities for interprofessional education
(IPE) and teamwork are essential in the
preparation and continuing education of
all primary care team members, including
registered nurses. This theme cuts across all
prior recommendations on education and
faculty development, but conferees felt it was
of such paramount importance that it should
be reinforced as a separate recommendation.
Actionable Recommendations
1. All primary care nursing education
curricula should incorporate core
interprofessional competencies, such as
those developed and disseminated by the
Interprofessional Education Collaborative
and the Quality and Safety Education for
Nurses Institute. Additional foundational
support for IPE curriculum development
is available from the National Center for
Interprofessional Practice and Education
and from the Institute for Healthcare
Improvement’s Open School. Essential
steps include:

Convene leading health professions
education and practice groups, and
patient and family representatives, to
co-develop the curriculum;

Identify competencies to prepare
registered nurses for expanded roles in
primary care; and
Ensure that the curriculum is deployed
in the continuum of education of current
and emerging primary care professionals.
One example of an educational tool that
includes interprofessional elements is
the American Academy for Ambulatory
Care Nursing’s modules for clinical care
coordination and transition management.
2. Deans and faculty should position students
from all professions to bridge and accelerate
the connection of academia and practice and
to drive change in practice sites. For example,
have students from multiple professions work
with a shared panel of high-risk primary care
patients or engage in a classroom discussion
about best practices in primary care.
3. Deans and faculty should leverage technology
as a catalyst to spread innovative curricula
and collaborative practice in primary care.
Technology fosters better education and
collaboration in primary care teamwork. For
example, simulations may be used to model
important resource management challenges.
One scenario, for example, might require
all team members to use the same electronic
health record screens to record and integrate
information about a patient.
Preparing registered nurses for enhanced roles
in primary care is an urgent issue; exemplary
practices show that these enhanced roles are
To succeed in this endeavor, primary care
and nursing education need to undergo
fundamental culture change, assisted by the
engagement, support, and commitment of a
wide variety of stakeholders. Patients will be
the ultimate beneficiaries.
The conclusions and recommendations from a
Macy conference represent a consensus of the group
and do not imply unanimity on every point. All
conference members participated in the process,
reviewed the final product, and provided input
before publication. Participants are invited for their
individual perspectives and broad experience and
not to represent the views of any organization.
The Josiah Macy Jr. Foundation is dedicated to
improving the health of the public by advancing
the education and training of health professionals.
Carmen Alvarez, PhD, RN, CRNP, CNM
Johns Hopkins University
Erica Arana, RN, DNP, PHN, CNS, CNL
University of San Francisco
Cynthia C. Barginere, DNP, RN, FACHE
Rush University College of Nursing
Debra J. Barksdale, PhD, FNP-BC,
Virginia Commonwealth University
Kenya Beard, EdD, GNP-BC, NP-C,
Jersey College
Judith G. Berg, RN, MS, FACHE
Bobbie Berkowitz, PhD, RN, FAAN*
Columbia University School of Nursing
Mary Beth Bigley, DrPH, MSN,
Health Resources and Services
Thomas Bodenheimer, MD, MPH*
University of California, San Francisco
School of Medicine
Erin Fraher, PhD, MPP
The University of North Carolina
at Chapel Hill
Robyn L. Golden, MA, LCSW
Rush University Medical College
Andrew Harmon, BS
Thomas Jefferson University College of Nursing
Thomas A. Sinsky, MD
Medical Associates Clinic
Alice D. Smith BSN RN
Harvard Vanguard Medical Associates,
Atrius Health
Laura Hieb, MBA, BSN, RN, NE-BC
Oconto Hospital and Medical Center
Beth Ann Swan, PhD, CRNP, FAAN*
Thomas Jefferson University College of Nursing
Anne Jessie, DNP, RN
Carillion Clinic
George E. Thibault, MD*
Josiah Macy Jr. Foundation
Gerri Lamb, PhD, RN, FAAN
Arizona State University College of Nursing
and Health Innovation
Donna Thompson, RN, MS
Access Community Health Network
Diana J. Mason, PhD, RN, FAAN*
Hunter College, City University of New York
Peter McMenamin, PhD
American Nurses Association
Storm L. Morgan, MSN, RN, MBA
U.S. Department of Veterans Affairs
Andrew Morris-Singer, MD
Primary Care Progress
Peter I. Buerhaus, PhD, RN, FAAN
Montana State University College of Nursing
Mary Naylor, PhD, RN, FAAN
University of Pennsylvania School of Nursing
Ellen Chen, MD
San Francisco Health Network
Jack Needleman, PhD, FAAN
UCLA Fielding School of Public Health
Marilyn P. Chow, PhD, RN, FAAN
Kaiser Permanente
Camille Prado, BS, RN
University of California, San Francisco
Pamela F. Cipriano, PhD, RN,
American Nurses Association
Joyce Pulcini, PhD, RN, PNP-BC, FAAN*
The George Washington University School
of Nursing
Jason Cunningham, DO
Sebastopol Community Health Center
Lisa Rivard, RN, CDE
Scripps Health and Neighborhood Health
Care Clinics
Margaret Flinter, APRN, PhD, FAAN,
Community Health Center, Inc.
Karla Silverman, MS, RN, CNM
Primary Care Development Corporation
Susan B. Hassmiller, PhD, RN, FAAN
Robert Wood Johnson Foundation
Janice Brewington, PhD, RN, FAAN
National League for Nursing
Malia Davis, MSN, RN
Clinica Family Health Services
Stephen C. Schoenbaum, MD, MPH*
Josiah Macy Jr. Foundation
Sandra Ryan, RN, MSN, CPNP, FCPP,
Deborah Trautman, PhD, RN, FAAN
American Association of Colleges of Nursing
Ellen-Marie Whelan, PhD, RN,
Center for Medicaid and CHIP Services
Centers for Medicare and Medicaid Innovation
Danuta M. Wojnar, PhD, MN, MED,
Seattle University College of Nursing
Peter Goodwin, MBA
Josiah Macy Jr. Foundation
Yasmine R. Legendre, MPA
Josiah Macy Jr. Foundation
Cheryl Sullivan, MSES
American Academy of Nursing
Ellen J. Witzkin
Josiah Macy Jr. Foundation
Teresa Cirillo
Teri Larson
Teri Larson Consulting
*Planning Committee Member
44 East 64th Street, New York, NY 10065
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June 15–18, 2016 | Atlanta, GA
Registered Nurses: Partners in Transforming
Primary Care: Recommendations from the Macy
Foundation Conference on Preparing Registered
Nurses for Enhanced Roles in Primary Care

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