In health care systems nationally and globally, RNs are key members of interprofessional care teams. Improving the health and health outcomes of diverse populations is a top priority of these health care teams. According to the Institute of Medicine (IOM, 2012), primary care is the delivery of comprehensive, accessible health care services by health care providers who are educated to: (1) address and meet individuals’ personal health care needs, (2) develop sustained relationships with patients, and (3) account for the social determinants of health and environment of individuals, families, and communities (IOM, 2012). Primary care registered nursing involves a comprehensive, preventively focused continuum of care for individuals, families, and communities that includes well-coordinated, sustained nurse/patient relationships to address their personal health and health care needs. RNs have skills sets in leadership, management, clinical practice, judgment and reasoning that can enhance primary care health care teams and thus improve the health and health outcomes of individuals who today often present with complex or chronic health conditions (Improving Primary Care, 2018).
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Global populations are experiencing an increase in the number of older adults aged 65 years and older who are living longer than in years past. For example, United States (U. S.) Census Bureau projections show that by 2050 there will be 83.7 million people aged 65 years and older (Ortman, Velkoff, & Hogan, 2014). Older adults in the U. S. and the world will require complex primary care needs because current trends reflect that many will be living with at least one chronic disease and many may have co-morbidities or various conditions, including mental health and substance abuse (Bodenheimer & Mason, 2017). Improving the health and health outcomes of people, young and older, calls for interprofessional health care teams that are well-educated in all aspects of health care navigation, management, and treatment, particularly in primary care.
Registered nurses are in prime positions to take leadership roles among interprofessional primary care teams to provide assessable value related to quality of care, improved health and health care outcomes, and cost-beneficial savings (Smolowitz et al., 2015). Flinter et al. (2017) identified emerging activities and leadership roles for RNs in primary care that involved more direct patient care, care management and navigation, and increased autonomy in patient care owing to better RN professional satisfaction. Moreover, Funk and Davis (2015) described an RN “co-visit” in which the RN obtains and records history of present problem, vital signs, past medical and social histories, as well as, application of standing orders and documentation of a nurse note for the health care provider to review and clarify during a joint visit with a patient. Promoting education in primary care for baccalaureate nursing students to practice to their full scope of their licensure, knowledge, and skills is of paramount importance to address the complex health care needs of people, young and older.
Initiatives and proposals to enhance and advance registered nursing in primary care have gained impetus and support. For example, funded by a grant awarded by the Health Resources and Services Administration, the Advancing Community Oriented Registered Nursing (ACORN) Project was launched at the University of Texas Health San Antonio School of Nursing in July 2018. The purpose of the ACORN Project is to recruit and educate baccalaureate nursing students in the expanding role of RNs in primary care. A key aim is to prepare baccalaureate nursing students in leadership roles to practice to the full scope of their licensure in primary care settings. In answer to the call to action to strengthen and expand primary care registered nursing, the ACORN Project’s beginning steps included: 1) convening meetings with faculty to share ideas, 2) creating a Community Leadership Advisory Board (C-LAB) to establish community partner support and join-in, and 3) promoting conference call and email communications with the other Texas universities who were awarded funding to advance primary care nursing to share implementation and progress of our respective projects.
The ACORN faculty developed a recruitment plan for baccalaureate nursing students who were interested in primary care to apply for the project. Information sessions were conducted to provide junior nursing students with information about primary care, our project, and requirements to apply. Interested students completed an application and submitted an essay describing their thoughts and knowledge about primary care and why they were interested in it. Students then went through a rigorous interview process in which two faculty members scored each student’s set of interview responses using a rubric to ensure systematic objectivity and inter-rater reliability. A cohort of five students was selected to participate in the beginning year of the ACORN Project and receive tuition assistance and monthly stipends. At a meeting to introduce these stellar, selected students to the C-LAB and faculty, students expressed their pride and excitement of this opportunity to learn and practice primary care registered nursing.
To introduce the ACORN students to primary care nursing, they will spend clinical hours with preceptor RNs in a primary care clinic that provides health care to young and older veterans with chronic conditions, including mental health and substance abuse. During the summer when these students are not in class, they will engage in primary care activities and experiences in various clinics: 1) the PRIDE Clinic that serves the LGBTQ community, 2) a Refugee Clinic that serves refugees from various countries, and 3) our nursing school’s mobile unit that serves underserved and rural populations. In their semester before graduation, ACORN students will receive further experiences and clinical hours in community oriented settings and population health with a final immersion course in which they will work side-by-side with a preceptor RN in a primary care clinical site. Project evaluation measures will include: 1) focus group interviews, 2) demographic and observational data, 3) pre- and post student experience comparison, 4) preceptor RN surveys, and 5) student reflective journaling. The ACORN Project model is setting a pathway for students to succeed and advance their knowledge and practice of community oriented registered nursing among interprofessional primary care teams to ultimately serve underserved and rural populations.
Conclusion
Designated the most trusted profession for the past 16 years (American Hospital Association, 2018), RNs are in a vital positionto transform the culture of teaching and practicing primary care globally. The importance of transforming the culture in academia and practice to expand primary care and the role of RNs to the full scope of their licensure in direct care and leadership is evident in the literature (Bodenheimer & Mason, 2017; Flinter et al., 2017; Funk & Davis, 2015; Smolowitz et al., 2015). The ACORN Project will continue through June 2021 with a yearly increase of students who are afforded the opportunity to gain knowledge and skill sets in community oriented registered nursing among interprofessional primary care teams. Future support to sustain innovative programs and projects, such as the ACORN Project, is justified to aid in addressing and meeting the needs of people, young and older, globally.