1. Ricciardi, Richard PhD, RN, NP

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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.



The reality is that there is a significant gap between our nation's demand for primary care and the number of primary care physicians available to meet that demand. Approximately 8000 primary care physicians enter the workforce each year, but the number of primary care physicians who retire each year is projected to reach 8500 by 2020.6 We already have a shortage of primary care providers, and the rate of retirement is about to outpace that of new entrants.


In a society in which our population is both growing and aging (and thus demand is increasing), this is unsustainable. A gap is inevitable, which should translate into an opportunity for NPs, physician assistants (PAs), and RNs. Market demands alone indicate that more patients will need to have their primary care largely overseen by an NP or a PA using a team-based approach.


Let us pause here to declare unambiguously that NPs and PAs are not replacements for physicians. This is an important distinction that needs to be stated clearly. Rather than competing with physicians, NPs, PAs, and RNs must collaborate with them as part of a complex, adaptive health care system in which the collective capability of the team is greater than that of a single individual.


Seminal reports by the National Academy of Medicine, the National Governors Association, and the Federal Trade Commission support the importance of the role of nurses as we move to change the paradigm of health care delivery to team-based models, in which all professionals play a distinct and vital role.7-9 By capitalizing on the full potential of all health care professionals, we can optimize the goal of delivering the right care to the right patient, at the right time, in the right place, by the right provider, for the right price.



When RNs, including but not limited to NPs, work well with physicians and other health care professionals in the primary care setting, patients benefit. But we know that working in teams does not always come easily. This is why AHRQ, along with the Department of Defense, developed TeamSTEPPS (Team Strategies & Tools to Enhance Performance and Patient Safety), an evidence-based curriculum to improve communication and teamwork skills among health care professionals.10 Regular readers of this journal are likely familiar with TeamSTEPPS, which provides higher-quality, safer patient care by producing highly effective health care teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients.11


A version of this curriculum, TeamSTEPPS for Office-Based Care,12 specifically addresses issues and problems unique to the ambulatory care setting. Importantly, TeamSTEPPS courses can be taken online and for continuing education credits through a learning management system that provides opportunities for nurses and other primary care team members to work at their own pace to obtain a TeamSTEPPS Master Trainer certificate.13


In addition to facilitating teamwork, AHRQ has several resources that promote patient and family engagement. Many of these are specific to or tailored for the office setting.14 This is important because research shows that when patients are engaged with their health care, it can lead to measurable improvements in safety and quality.


One example is the "warm handoff," a transfer of care from one member of a health care team to another. Oftentimes, a nurse is involved. What makes it "warm" is the presence of the patient and his or her family, who are there to participate in the handoff. This transparency allows patients and families to hear what is said and check for accuracy, giving them the opportunity to clarify or correct information or ask questions. AHRQ's Warm Handoff Implementation materials15 can help nurses and other primary care providers engage with patients in a way that will protect safety and enhance quality.


AHRQ is making available other research and tools that help make care safer in the ambulatory setting. These can be found at



We know that primary care resources are in high demand. We also know that nurses are uniquely positioned to meet the initial needs of large numbers of patients. However, we must confront several significant challenges that keep RNs from assuming a more active leadership role in primary care. These challenges include the following: (1) most prelicensure nursing programs do not have a focus on primary care; (2) evidence is nascent on the return on investment and the full quantifiable value of using RNs in primary care; and (3) RNs are often viewed, shortsightedly, as a revenue drain rather than as an important contributor to primary care in a fee-for-service reimbursement environment.16


May I suggest we consider a "back to the future" approach? Decades ago, nurses in many areas were the chief providers of primary care. This was especially true in rural or inner-city areas, places that today we would call medically underserved communities. This practice waned, especially after World War II, as medicine and hospitals evolved. There is no reason why the status quo cannot evolve once again.


Change will not be easy. It will require that we be mindful of the impact on our colleagues in the health professions, including physicians; that we make the business case for it; and that we undertake every aspect of change with the patient at the center of the process. This final point-the importance of being patient-centric-is where AHRQ's resources are so important. Primary care providers must protect the safety of patients and deliver the highest-quality care possible. RNs can enhance quality and safety and are well positioned to use AHRQ tools to do so. If we get this right, everyone-physicians, nurses, PAs, all members of the primary care team, and, most importantly, patients-will win.




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2. American Association of Nurse Practitioners. AANP National Nurse Practitioner Database. Austin, TX: American Association of Nurse Practitioners; 2017. [Context Link]


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7. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2010. [Context Link]


8. National Governors Association. The role of nurse practitioners in meeting increasing demand for primary care. https:// Accessed August 7, 2017. [Context Link]


9. Federal Trade Commission. Policy perspectives: competition and the regulation of advanced pract-ice nurses. https:// Published March 2014. Accessed August 7, 2017. [Context Link]


10. Agency for Healthcare Research and Quality. TeamSTEPPS National Implementation. Rockville, MD: Agency for Healthcare Research and Quality. Accessed July 11, 2017. [Context Link]


11. Brady J, Battles JB, Ricciardi R. Teamwork: what health care has learned from the military. J Nurs Care Qual. 2015;30(1):3-6. [Context Link]


12. Agency for Healthcare Research and Quality. TeamSTEPPS for Office-Based Care Version. Rockville, MD: Agency for Healthcare Research and Quality. https:// Accessed July 11, 2017. [Context Link]


13. Agency for Healthcare Research and Quality. Welcome to the TeamSTEPPS(R) LMS. Rockville, MD: Agency for Healthcare Research and Quality. Accessed July 12, 2017. [Context Link]


14. Agency for Healthcare Research and Quality. Patient and Family Engagement in Primary Care. Rockville, MD: Agency for Healthcare Research and Quality. https:// Accessed July 12, 2017. [Context Link]


15. Agency for Healthcare Research and Quality. Warm Handoff: Intervention. Rockville, MD: Agency for Healthcare Research and Quality. https:// Accessed July 12, 2017. [Context Link]


16. Bodenheimer T, Bauer L, Syer S, et al RN Role Reimagined: How Empowering Registered Nurses Can Improve Primary Care. Oakland, CA: California HealthCare Foundation; 2015. [Context Link]