Second is providing staff/professional development for current primary care RNs to enhance their skills and take on new and more autonomous roles.
Third is providing training and education to registered nurses with expertise in the in-patient or other non-primary care settings to practice effectively in primary care.
Registered Nurses for the Primary Care ::
Preparing new Registered Nurses
First in the education continuum is educating new RNs—students in pre-licensure programs. The majority of clinical experiences in nursing programs continue to be in the in-patient care setting, with some limited exposure to public health, home care, or community health nursing roles.Few pre-licensure nursing programs provide ambulatory or primary care clinical experiences in their standard curriculum.
Those nursing schools that run nurse-managed centers and/or mobile vans do provide some primary care and team-based care experiences for RN students, but this could be expanded.
Nursing educators often cite several reasons for maintaining the in-patient clinical education focus in pre-licensure programs. For example, the in-patient setting offers more opportunities for students to quickly master the required technical nursing skills.
Further, achieving the required student-to-preceptor ratio is more challenging in the ambulatory/primary care setting as space and other constraints limit the number of students that can be in the clinic/team at any one time.
Also the high-intensity pace of moving many patients through a three-hour session limits the preceptor's time with students, and thus the level of students appropriate for this setting. And, finally, there is a lack of nursing preceptors who have experience and feel comfortable teaching in the primary care setting.
Unfortunately, then, most pre-licensure students have no exposure to ambulatory/primary care in their formative education years and thus little desire or preparation to work in these settings after graduation.
Training for the ambulatory/primary care nursing model, and particularly for the new RN roles, is challenging and requires dedicated time for practical experiences as the care delivery model is vastly different from the acute setting.
Two strategies to prepare new RNs are nurse residency programs and dedicated clinical experience in the form of extended clinical rotations or a dedicated education unit (DEU).
The American Association of Ambulatory Care Nurses (AAACN) has advocated for RN ambulatory residencies to develop RN skills in primary care.18 To the best of our knowledge, however, residency programs in primary care have not yet been developed for RNs who have completed a bachelor of science in nursing degree.
Such programs could be modeled on the successful post-graduate residency training programs for new APRNs in FQHCs, which are now well established.
The DEU, which began in acute care, is now being implemented in primary care at one FQHC with support from a HRSA initiative focused on improving interprofessional collaborative practice and education.
The DEU concept was originally developed in Australia at the Flinders University School of Nursing to address the issue of fragmented and time-limited training for RNs.
In a primary care DEU, the RN student can experience all facets of the RN role, as well as experiencing a truly interprofessional collaborative practice environment.
No matter where the RN decides to practice ultimately, he/she would have the tools to function on a team and to better understand this part of the continuum of care. A DEU allows for the exchange of hands-on clinical pearls from those currently delivering the care to those in the next generation.
It provides the support and practice to develop therapeutic language when working with patients, and to master skills such as motivational interviewing when engaging the patient as a member of their own care team. This type of experience and support builds self-confidence, clinical competence, and critical thinking skills to function independently as an RN in primary care.
Building nurse residency programs and DEUs requires close partnerships between nursing education programs and primary care settings. While relationships exist between hospitals/health systems and nursing programs, they may not extend to the affiliated ambulatory/primary care practices or the independent primary care sites in the community.
Nursing programs would benefit from concerted outreach to these types of practices to establish clinical teaching relationships beyond acute care.
Staff and professional development for new RN roles
The challenge is not only to prepare the next generation of new RNs to practice in primary care, but also to support primary care RNs who may now be practicing in a limited role and need to master new skills for new roles.For the RN whose role in the practice is continually evolving, the level of autonomy and independent judgement required may be, frankly, frightening and extremely uncomfortable. When one team member's role changes, the roles of all members change.
This affects each staff member, not just the core and extended care teams, but also the patients and the lay staff, such as receptionists.
Many primary care practices have implemented their own formal staff development programs on-site for RNs and other clinical and lay staff members, while others have contracted with local community colleges or training programs.
One innovative strategy for both role development and content knowledge expansion that has been pioneered at CHCI is Project ECHO—RN Complex Care Management (CCM).
Dr. Sanjeev Arora began Project ECHO at the University of New Mexico as a telehealth program to support primary care providers treating hepatitis C, without requiring the patients to travel to the university to see Dr. Arora and his team.
The hope was to improve adherence and treatment support for patients through building PCP knowledge and self-efficacy in treating their own hepatitis C patients.
This model quickly grew to include other complex conditions such as HIV, endocrine, rheumatologic, and many others. CHCI replicated Project ECHO for hepatitis C and HIV,23 but then quickly added chronic pain, pediatric behavioral health, and even treatment support for providers caring for patients on buprenorphine. Just as PCPs need additional support to take on complex cases into their own care, RNs had a similar challenge.
Therefore, it was only natural that Project ECHO then be translated to fit a nursing model to support primary care RNs as a main focus, instead of the previously provider-centric model.
Once the initial training and competency is completed, ongoing support is critical since a key component of primary care nursing is the long-term relationship with the patient and family and maximizing opportunities to motivate and improve self-management.
This is a much harder competency to teach because it involves developing advanced communication and facilitation skills, along with motivational interviewing. Through Project ECHO CCM, RNs receive smaller, more manageable portions of content with specific didactic information over time, along with case-based feedback from expert, multi-disciplinary faculty.
This allows for ongoing hands-on learning, along with a level of support and supervision to ensure the full integration of new skills.
Re-training RNs to move from in-patient to primary care
For the RN transitioning from the acute care setting, the transition from intensive responsibility and patient engagement for a few days with a specialized patient population, to caring for individuals and families over years and encompassing virtually every health condition, can be overwhelming.RNs coming to primary care often welcome a "return" to the nursing care they once aspired to: direct, hands on, highly engaged, family-involved, and holistic, with a focus on restoring health in the context of family and community.
But the transition to a primary care role is a slow process. The combination of role change and content knowledge requirements necessitates learning in the practice setting with expert mentors and a planned curriculum.
This takes time, faculty, planning, and ongoing assessment. While this can be done within the context of formal on-the-job training given appropriate time and resources (especially for current staff who are expanding their roles), we strongly advocate for the concept of residency, not just for new RNs but for RNs who are transitioning from the in-patient to the primary care setting.
Career ladders for RNs in primary care
If we aim to attract and retain the best and brightest RNs to primary care, what opportunities do we offer them for career advancement? Practices should clearly identify what the opportunities are for advancement, both at the current level of education/certification and with further education and training, hopefully supported by robust tuition reimbursement and other policies.Advancement may be within the practice of nursing or movement into other fields where such transitions would not be viewed as a loss. The trajectory from RN to APRN and on to further advanced degrees is obvious, but so is the potential for advancing within the primary care practice to greater responsibility or specialization within primary care, as well as management and leadership.
Ideally, the primary care practices of the future will find RNs embedded at every level, from the primary care team to the c-suite, from the QI department to the business intelligence team, from the telehealth connection to the homeless shelter or school-based clinic.
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