Primary care had its origins in Britain about 100 years ago and is the foundation of most international health care systems, yet the vision for and outcomes of primary care in the United States actually lags far behind those of other developed countries (Macinko, Starfield, & Shi, 2003; Starfield, 1992) (See Figure 1). Historians remind us that at one time, all health care was once really primary care, and that in reality the United States, unlike other countries, developed a fixation on specialty care in the last century (Howell, 2010). Before World War II, most Americans’ health care was provided by a generalist physician and specialists would be seen only if referred. Throughout the 1930s and 1940s, primary care expanded to include pediatricians, internists, and public health nurses (IOM, 1996). The use of the term primary care began in the late 1960s; at the same time, there was a growth in specialist physician care. It wasn’t until 1969 that family medicine was approved as a specialty, just after the first NP program started.

The triad of circumstances in the 1960s—President Kennedy’s assassination, President Johnson’s “War on Poverty,” and the women’s movement—sparked a widespread commitment to public service and instigated a revaluing of nursing that encompassed women’s work, caring, ethics, and knowledge. These social forces, coupled with a physician workforce misdistribution, provided a powerful social context to lay the groundwork for a demonstration project at the University of Colorado to build on and reclaim the role of the public health nurse. Thus, the role of NPs began and was historically rooted in primary care. This emerging NP model was extraordinarily patient-centered. It was distinct from the medical model of that time in that it focused on prevention, health and wellness, patient education, and including the patient as a partner in making clinical decisions and cost-benefit alternatives so that patients were empowered to weigh treatment options.

The 1970s brought a rapid influx of capitated group practice models, or health maintenance organizations (HMOs), which emphasized primary care and lower hospitalization rates. The expansion of the HMO grew out of the Health Maintenance Organization Act of 1973, which intended to control expenditures for employers who offered health insurance benefits. Despite these efforts, primary care did not flourish for a number of reasons, one of which was that the role of primary care as gatekeeper was perceived as a barrier for patients’ access to specialty care by physicians. Today, patients who enroll in HMOs are often assigned to a primary care physician. Each full-time physician is assigned, or empanelled, with approximately 1500 patients to care for (Murray, Davies, & Boushon, 2007). Some HMOs and other third-party insurers do not empanel NPs or list them as primary care providers, rendering NPs’ contribution to primary care invisible. NP empanelment would provide a basis for measuring the effectiveness of NPs more accurately, whose services are often now significantly underestimated because they are recorded as being provided by their collaborating physicians (Naylor & Kurtzman, 2010; Pohl, Hanson, & Newland, 2010).

More recently, the PCMH concept has been highly acclaimed as improving outcomes and management of complex chronic diseases (Nutting, Crabtree, Jaen, et al., 2009). It is a model of health care that embodies the full spectrum of primary care based on patient-centered care, clearly defined provider-patient relationships, and primary care standards of accessibility, continuity, comprehensiveness, integrated care, and interdisciplinary care (Keckley & Underwood, 2008). Most of primary care practice has been considered a cottage industry, with many small businesses (physician practices that employ NPs) that are not integrated vertically with other sectors of the health care system. Historically, NPs worked as employees in group physician practices who operated in a predominantly fee-for-service delivery system. With the move toward ACOs, this trend is likely to change. The relationship of NPs as employees of private, physician-owned businesses has led to the lack of data on NP primary care practice. Some primary care NPs are associated with academic or medical center primary care services, although a few are also connected with nurse-managed health centers (NMHCs) and other nurse-led primary care practices.

Since the first primary care NP role, which focused on the care of children, a variety of primary care NP foci have emerged over 4 decades, emphasizing care to specific populations such as families, adults, older adults, and women. All these roles were conceived to increase access to primary care and address the needs of underserved populations. NPs have been acknowledged as high-quality, cost-effective providers of primary care (Brown & Grimes, 1993; Cook & Nolan, 1996; Laurant et al., 2005; Mundinger et al., 2000; Newhouse et al., 2011).

Federal Government and Primary Care

The Patient Protection and Affordable Care Act (PPACA), passed in 2010, has far-reaching goals to address access to care and emphasize primary care, including health promotion (U.S. Department of Health and Human Services [HHS], 2011). It will be phased in over time, with comprehensive implementation by 2014, and will give an estimated 32 million more people in the United States access to health care. Because of its emphasis on primary care and the significant shortage of primary care physicians, NPs and other advanced practice nurses (APNs) will play a major role in providing access to quality care under the PPACA. It is expected that the PPACA will expand opportunities for the PCMH, community health centers (CHCs), NMHCs, and ACOs. These will be discussed later in the chapter.

Health Resources and Services Administration

The Health Resources and Services Administration (HRSA), an agency of the HHS, is the primary federal agency for improving access to health care services for people who are uninsured, isolated, or medically vulnerable. HRSA’s Bureau of Primary Care funds grants that build a safety net infrastructure in high-poverty counties, such as CHCs that provide primary health care, regardless of the person’s ability to pay. The Bureau of Health Professions funds grants to schools of nursing through its nursing education, practice, quality, and retention grants; their purpose is to provide support for academic, service, and continuing education projects, in part to increase nurse retention and strengthen the nursing workforce (HRSA, 2012a). Although this funding is not directed solely to primary care, it has helped fund NMHCs that provide primary care; often, these centers serve the underserved.

Health Professional Shortage Areas Designation

About 20% of the U.S. population (60 million people) reside in health professional shortage areas (HPSAs). One criterion for this shortage designation is a community that has a population of 3500 but only one full-time primary care physician in one of the four primary care specialties—general or family practice, general internal medicine, pediatrics, and obstetrics and gynecology (Council of State Governments, 2008; HRSA, 2012b). Of those 60 million people living in HPSAs, about 34 million are considered to be medically underserved. Currently, NPs, certified nurse-midwives (CNMs), and physician assistants (PAs) are not included in the counts of primary care providers for the HPSA designation, for several reasons, but they are critically important for the APN community. First, there is concern that counting NPs and CNMs would render communities ineligible for a shortage designation because they would raise the eligibility ratio higher for communities that had APN(s) to more than the population-to-provider ratio of 3500 : 1, thus creating a catch-22. Second, the outdated state practice acts governing NP and CNM practice vary widely; some state laws permit independent APN practice, whereas others are highly restrictive. This variability across states introduces systematic bias in counting them as full-time equivalent primary care providers, because an APN in a restrictive state is not able to practice to full capacity because of restrictive laws. Finally, and perhaps most importantly, there is a substantial lack of data on the location and practice patterns of NPs. The IOM report, The Future of Nursing (2011), has identified this lack of data as critical for sound decision making. Individual NP organizations have tried to track data on their members, but there is no comprehensive national data set on NPs or APNs.

Centers for Medicare & Medicaid Innovation

The Centers for Medicare & Medicaid Innovation was established by the PPACA, is intended to revitalize and sustain Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP), and ultimately improve the health care system for all Americans. The Innovation Center has the resources and flexibility to test innovative care and payment models rapidly and encourage the widespread adoption of practices that deliver better health care at lower cost. This Center will be significant for establishing new models of care and has potential for testing nurse-led models, as well as innovations in which nursing is a significant part of the team. Some of these models will be addressed later in this chapter.

Primary Care Workforce Composition

The National Sample Survey of Registered Nurses in 2010 (based on data from 2008; Table 15-1) estimated that there were 250,527 registered nurses (RNs) prepared as APNs in one or more areas. Of these, 220,494 were employed in nursing (HRSA, 2010). NPs represented the largest group of APNs, approximately 154,000; this includes NPs who identify themselves as both a clinical nurse specialist (CNS) and NP. However, this figure is only an estimate of the NP primary care workforce because no national data have analyzed practicing NPs by specialty or focus (e.g., acute care, gerontology, family). The 2012 graduation data (American Association of Colleges of Nursing [AACN] & NONPF, 2013), shown in Table 15-2, suggest that most NP graduates (82%) select primary care specialties. Although these graduation data do not fully inform the current workforce composition, they do suggest that most NPs choose primary care as their focus and are potential primary care workforce providers. The enrollment and graduation rate of NPs over the past 3 years continues to rise, with an annual graduation rate increasing overall by more than 1000 annually, and with most of the graduates prepared in primary care. This is a different picture from physician data. Family practice, for example, is the largest primary care specialty in medicine. Over the last 2 years, only 1184 and 1317 U.S. medical students each year chose residencies in family medicine (American Academy of Family Physicians [AAFP], 2011), compared with closer to about 12,000 primary care NPs graduating in 2012 (AACN & NONPF, 2013). These estimates, and the dearth of data on the NP workforce, make a compelling case for more robust workforce data on NP practice patterns, distribution, and impact on outcomes. However, the data we do have are compelling in terms of the key role that NPs will need to play in addressing the primary care needs of the nation with the implementation of the PPACA.

TABLE 15-1

Composition of the Primary Care Workforce

This survey is a sample of the registered nurse population, not the subpopulation of NPs, making the accuracy of the NP estimate less reliable. Moreover, this estimate reflects all NPs in all specialties and settings, making it an overestimate for the primary care workforce. There are no national workforce data on NPs by specialty certification.

^*From U.S. Department of Health and Human Services, Health Resources and Service Administration (HRSA). (2010). The registered nurse population: Findings from the March 2008 national sample survey of registered nurses (http://bhpr.hrsa.gov/healthworkforce/rnsurvey2008.html).

^†Bureau of Labor Statistics. (2011). Occupational employment and wages, May 2011: 29-1071 Physician assistants (http://www.bls.gov/oes/current/oes291071.htm).

^‡Agency for Healthcare Research and Quality Primary Care. (2011). Workforce facts and stats no. 1. The number of practicing primary care physicians in the United States (http://www.ahrq.gov/research/ pcwork1.htm).

TABLE 15-2

2012 Graduates of Masters, Post-Masters, and Post-Baccalaureate DNP-Level Nurse Practitioner Programs *

NP = Nurse Practitioner.

^*Percentages may not total 100 due to rounding.

From American Association of Colleges of Nursing and National Organization of Nurse Practitioner Faculties. (2013). Annual survey. Washington, DC: Authors.

The Doctor of Nursing Practice

In response to the need to support the advanced educational needs of the APN, the Doctor of Nursing Practice (DNP) is the expected requirement for APN preparation in the future. Endorsed by AACN, the DNP is a practice-focused doctorate designed to “prepare experts in specialized advanced nursing practice” (AACN, 2004). Foundational competencies and competencies in areas of specialization and role are included in DNP preparation. The DNP Essentials (AACN, 2006) outline specific foundational competencies and learning experiences in a variety of settings so that the broad consequences of decision making can be identified. These competencies are central to current APN practice and are particularly salient to primary care advanced practice. Many DNP programs started out as post-masters programs, but there are increasing numbers of post-baccalaureate programs that include NP preparation in their course of study. Although the numbers are still very small, they were included in the data presented in Table 15-2.

Nurse Practitioner Role and Competencies in Primary Care

Nurse Practitioners in Primary Care: A Role in Advanced Practice Nursing

Foundational to NP graduates overall, and specifically NPs in primary care, is that they have knowledge, skills, and abilities essential to independent and direct clinical practice (see Chapter 7, NONPF, 2012). The NP core competencies are acquired throughout an NP’s educational program through mentored patient care experiences, with emphasis on independent and interprofessional practice; analytic skills for evaluating and providing evidence-based, patient-centered care across settings, and advanced knowledge of the health care delivery system. Doctorally prepared NPs apply knowledge of scientific foundations in practice for quality care. They are able to apply skills in technology and information literacy and engage in practice inquiry to improve health outcomes, policy, and health care delivery. Areas of increased knowledge, skills, and expertise include advanced communication skills, collaboration, complex decision making, leadership, and the business of health care. The NONPF core competencies build on the APN competencies described in Chapter 3 and throughout this text. They also build on previous work that identified knowledge and skills essential to Doctor of Nursing Practice (DNP) competencies (AACN, 2006; NONPF & National Panel, 2006) and are consistent with the recommendations of the IOM report on The Future of Nursing (2011). Box 15-1 cross-maps the seven APN competencies from Chapter 3 and the nine NP core competencies (NONPF, 2012). The competencies described in the following section reflect some of the selected core competencies for all APNs, as presented in Chapter 3, as well as the nine NONPF core competencies for all NPs relevant to the NP in primary care (NONPF, 2012). The NONPF core competencies were developed by integrating existing Master’s and Doctor of Nursing Practice (DNP) core competencies. They are guidelines for educational programs preparing NPs to implement the full scope of practice as licensed independent practitioners. The competencies are essential proficiencies for all NPs and should be demonstrated on graduation. The competencies are specific to the NP role and prepare NPs, regardless of the population focus, to meet the complex challenge of translating rapidly expanding knowledge into practice and enable NPs to function in a changing health care environment. We will apply the APN and NP core competencies to the NP in primary care.

Box 15-1

Cross Mapping of Advanced Practice Nurse Competencies and National Organization of Nurse Practitioner Faculties Nurse Practitioner Competencies

Adapted from National Organization of Nurse Practitioner Faculties (NONPF). (2012). Nurse practitioner core competencies (http://nonpf.org/associations/10789/files/NPCoreCompetenciesFinal2012.pdf).

Advanced Practice Nurse Core Competencies

Coaching and Guidance

The relationship between the primary care NP and the patient creates a strong foundation for the coaching and guidance competency (see Chapter 8). The coaching and guidance competency overlaps with the independent practice competencies and technology and information literacy NONPF NP competencies.

A challenge for the primary care provider is to identify serious illness and involve other disciplines in the care of the complex patient. Exemplar 15-2, with LM, illustrates the coaching competency. It also shows how the NP collaborates with other health care professionals to provide comprehensive care to complex patients. In this case, LM’s NP may be the first provider to see the young adult with an eating disorder.

Coaching and guidance is exemplified in Exemplar 15-1, in which CL (the NP) addresses the broad array of developmental and age-related concerns of a young adult who she has followed since her late teens. High-risk behaviors had been addressed in earlier years and prevention is consistently emphasized. A strong relationship has developed, with an emphasis on coaching and guidance. CL also uses NP competencies, such as scientific foundations and health delivery system competencies. Over the years, CL continues to develop the partnership with the patient. NPs have a deep knowledge of the change process and a menu of tools to use, depending on where the patient is in the cycle of change. Time is another tool for the primary care NP. As in the case of KI, the primary care NP is available to her longitudinally as she moves through developmental stages and health issues.

Consultation

Consultative relationships are critical to primary care NP practice. Relationships with other APNs, physicians, nurses, social workers, and other health care providers ensure that patients have access to comprehensive care. The exemplars illustrate different consultative relationships. In Exemplar 15-3, in which care is delivered in a nurse-managed health center, consultation is clearly evident through the use of technology and an electronic health record (EHR), making care seamless. Consultation can be formal, as reflected in Exemplar 15-3, or informal, with colleagues in one’s practice. This informal style is a frequent part of the daily rhythm of a nurse-managed center, as well as many primary care practices, and includes elements of the collaboration competency and independent practice. NPs in a smaller or solo practice may have to develop methods of consultation, as described in Exemplar 15-3. The increased use of technology in practice makes this more possible today.

NPs in primary care use other APNs as a consultant in their specialty areas. For example, the primary care NP might initiate a consultation with a psychiatric NP or CNS to evaluate depression in a hospitalized patient. In Exemplar 15-2, psychiatric consultation was sought to address an eating disorder. A referral for consultation with a CNM for preconception counseling provides valuable information to the woman ready to start a family. Newly diagnosed patients with type 2 diabetes benefit from consultation with a CNS whose specialty is diabetes management, and the expertise of home health nurses is critical in discharge planning. Community health nurses have a wealth of knowledge regarding other community resources and insurance coverage for home care services. NPs often initiate consultations with other health care professionals, including physicians, pharmacists, physical therapists, occupational therapists, speech therapists, nutritionists, and social workers.

Collaboration

The IOM definition of primary care (1996) implies the use of professional collaboration to deliver “integrated” and “accessible” care for all health care providers. The fiscal realities of practicing solo, in addition to the restrictions on NP practice imposed by state regulations, make a team approach the preferred choice for physicians and many nurses in primary care. Effective collaboration results in more comprehensive, patient-focused care (Bodenheimer & Grumbach, 2007) and it promotes high-quality, cost-effective outcomes (Cowan, Shapiro, & Hays et al., 2006). Most NPs practice in settings with physicians who are in a private practice or publicly funded practice, such as community health centers, the Veterans Administration (VA), or other government practices, including local health departments. Collaboration is seen as a professional ethic, central to primary care, and not easily regulated. All health professions collaborate on a regular basis to address the complex needs presented in primary care. It is an expected norm of primary care and not unique to NP practice. With the growth of the PCMH, collaborative and team practice will no doubt have an increasing prominence in primary care.

Most of the exemplars in this chapter include some form of collaboration, but Exemplar 15-6 describes a gerontology practice based on collaboration among physicians, NPs, other nurses, pharmacists and social workers. The practice is intentionally interdisciplinary, exceptionally collaborative, and team-based. Patients benefit from a team approach although an NP or physician may be the leader of a group of patients. This exemplar demonstrates independent practice (NP NONPF competency) of an NP within a strong team–collaborative model of care. Patients clearly benefit from this approach to care and, in primary care, it is increasingly becoming more common in a PCMH.

Nurse Practitioner Core Competencies

Independent Practice Competencies

The work of the primary care NP is based on the premise that individuals seek care for a broad range of health care concerns over time across the life span. Relationships evolve over time (e.g., Exemplars 15-1 and 15-6), which facilitates a sense of mutual respect and trust (NONPF, 2012). Within that relationship, a deep understanding of the patient’s life and the meaning of the illness or health issue at hand develops. It is essential for NPs to know their patients’ lives, including their family members, their jobs and careers, and their challenges in raising children, as well as caring for aging parents.

As clinicians, leaders, and role models, primary care NPs bring a holistic approach to care, an approach that directly affects the lives of individuals, families, and even whole communities. There are many social forces that emerge to shape the future health and professional practice environment for primary care NPs. Most importantly, the primary care NP needs to be prepared to function as a licensed independent practitioner and demonstrate the highest level of accountability for professional practice. In their practice, primary care NPs independently manage previously diagnosed and undifferentiated or undiagnosed patients and provide a full spectrum of health care services, including health promotion, disease prevention, health protection, anticipatory guidance, counseling, disease management, palliative care, and end-of-life care. The primary care NP is capable of using advanced health assessment skills to differentiate between normal, variations of normal, and abnormal findings and uses screening and diagnostic strategies in the development of diagnoses. Furthermore, she or he prescribes medications within the scope of practice and manages the health and illness status of patients and families over time.

Primary care NPs also need to be able to provide patient-centered care, recognizing cultural diversity and the patient or designee as a full partner in decision making. They should work to establish patient relationships characterized by mutual respect, empathy, and collaboration. They need to create a climate of patient-centered care that includes confidentiality, privacy, comfort, emotional support, mutual trust, and respect. They should incorporate patients’ cultural and spiritual preferences, values, and beliefs into their care. Finally, they should preserve a patient’s control over decision making by negotiating a mutually acceptable plan of care. The competency of independent practice is very similar to that of the APN’s direct clinical practice. It implies that every NP is responsible for the care that he or she delivers, including the quality of that care and the practice of collaboration and consultation.

Scientific Foundation Competencies

Complexity of care and an NP’s familiarity with patients is cultivated over a series of encounters. Although the hallmark of the primary care NP’s practice is the breadth of health issues encountered, the privilege of developing a patient-NP relationship occurs over time. This enables the NP to tailor evidence-based interventions to the patient and to sustain a holistic practice. As with other advanced practice roles, primary care NPs needs to have the ability to analyze data and evidence critically for improving advanced nursing practice. The scientific underpinnings of practice provide a basis of knowledge for advance nursing practice. Primary care NPs need to be able to integrate knowledge from the humanities and sciences within the context of nursing science. In particular, the primary NP should have a scientific foundation derived from the natural and social sciences and that might include human biology, physiology, and psychology.

Nursing science foundations have contributed to the discipline of nursing, which is characterized by a “unique perspective, a distinct way of viewing all phenomena, which ultimately defines the limits and nature of its inquiry” (Donaldson & Crowley, 1978, p. 113). According to the AACN DNP Essentials (2006), specific middle-range theories should be used to guide the practice of NPs. Primary care NPs may use middle-range theory to guide their assessment, decision making, and interventions, particularly when situations call for them (Lenz, 1998). Historically, nursing professionals have struggled to close the theory-practice gap because of lack of knowledge, understanding, and applicability of nursing theory to guide nursing practice (Kenny, 2006). Doctorally prepared NPs, in particular, should be capable of understanding middle-range theory and translating research and other forms of information to improve practice processes and outcomes. Ultimately, primary care NPs must be able to develop new practice approaches based on the integration of research, theory, and practice knowledge.

Leadership Competencies

Primary care NPs, particularly doctorally prepared NPs, are expected to assume complex and advanced leadership roles to initiate and guide change. This competency is similar to the APN competency of clinical, professional and systems leadership (see Chapter 11). Their leadership should foster collaboration with multiple stakeholders (e.g. patients, families, community, integrated health care teams, policymakers) and demonstrate critical and reflective thinking. Collaboration and leadership are closely linked in the effort to improve health care. In primary care, for example, the NP’s direct clinical practice with expert coaching and guidance exemplifies a collaborative relationship between patient and NP. The 1996 IOM definition of primary care implies the use of professional collaboration to deliver integrated and accessible care. Effective collaboration results in more comprehensive, patient-focused care (Bodenheimer & Grumbach, 2007) and promotes high-quality, cost-effective outcomes (Cowan et al., 2006). The NP’s expert coaching and guidance also require the establishment of a collaborative relationship between patient and provider (Dick & Frazier, 2006).

Moreover, primary care NPs should be capable of advocating for improved access, better quality, and cost-effective health care for all populations. They are able to use the development and implementation of innovations that incorporate principles of change to advance practice. They should also be able to communicate practice knowledge effectively, orally and in writing. At the local practice level, for example, NPs enact leadership roles when they guide and support staff, triage patients, and oversee the appropriate use of resources. NPs must ensure that primary care practices have an evidence base and that they use meaningful, systematic, quality improvement initiatives. On a broader level, primary care NPs engaged in clinical and professional leadership must also use effective collaborative skills to assist groups and organizations to envision preferred futures, achieve consensus, and implement change.

The essence of primary care is the sustained continuity of health care for patients and their families. As the long-term member of the entire team that provides continuity and stability in the care and management of patients over long periods, primary care NPs often emerge as leaders in health care settings. Additionally, the primary care NP’s role as a leader in the community via membership on boards of health and education, and as an influential policymaker, cannot be underestimated.

Quality Competencies

Rapidly rising health care costs are leading to a variety of changes in the U.S. health care system and are placing patients and providers in jeopardy. Patients risk losing out on effective, albeit costly, care. Increasing consumer desire for care oriented toward prevention, primary care NPs are presented with unique opportunities to contribute significantly in improving the quality and measurement of health care delivery and the patient’s health outcome. Ongoing monitoring and continuous improvement of practice outcomes is essential for all NPs, including those in primary care.

Primary care NPs are expected to use the best available evidence to improve the quality of clinical practice continuously. Ongoing evaluation of the relationships among access, cost, quality, and safety and their influence on health care is essential to the role that NPs play in health care. Primary care NPs need to be competent in evaluating how organizational structures, care processes, financing, marketing, and policy decisions affect the quality of health care. To ensure quality, primary care NPs need to apply skills in peer review to promote a culture of excellence and anticipate variations in practice. Also, they need to be proactive in implementing quality improvement interventions. NPs are expert clinical thinkers who listen carefully to the stories that their patients tell them. To ensure quality care, primary care NPs can partner with patients and families. Relationships with patients should always be therapeutic. As partnerships deepen, the relationship becomes an even more significant clinical tool. Quality outcome studies are presented later in this chapter.

Practice Inquiry Competencies

Expert clinical thinking and skillful performance are cultivated through repeatedly evaluating similar sets of health and illness scenarios and formulating plans of care based on patient expectations, standards of care, experience, clinical judgment, and current research. Primary NPs continuously synthesize knowledge and experience so that, over time, they acquire practical wisdom, defined by Oberle and Allen (2001) as “knowing when a particular action ought to be taken” (p. 151). Experienced APNs incorporate this practical wisdom into their decision making, taking actions that they might have been unlikely to take as novice practitioners.

An assessment of the chief complaint often unearths a multitude of issues and the patient may not be aware of all of these. The skilled practitioner helps the patient sort through the issues, establish priorities, and understand the interconnectedness of these priorities. Practical wisdom guides the practitioner to use expert clinical thinking and skillful interviewing to develop a prioritized plan of care that is likely to improve health and quality of life and to be carried out by the patient.

Primary care NPs play a critical leadership role in the translation of new knowledge into practice. To shorten the time spent translating bench science to bedside clinical practice, or for dissemination to population-based community interventions, primary care NPs are expected to provide leadership in translating new knowledge into practice and to generate knowledge from clinical practice to improve practice and patient outcomes. Thus, a primary care NP’s education should be sufficient to prepare her or him to apply clinical investigative skills to improve health outcomes and lead practice inquiry, individually or in partnership with others. Finally, the primary care NP should be able to disseminate evidence from such inquiry to diverse audiences using a number modalities. Practice inquiry and quality competencies are cross-mapped with the research competency of the APN in Box 15-1.

Technology and Information Literacy Competencies

There is extensive evidence linking information technology with improved patient safety, care quality, access, and efficiency (Fetter, 2009). Primary care NPs must demonstrate competencies in computers, informatics, and information literacy to use information technology for practice, education, and research. In particular, they need to be able to integrate appropriate technologies for knowledge management to improve health care and translate technical and scientific health information appropriate to various users’ needs. NPs rely on their technology and information literacy competencies to guide them in their assessments of patient and/or caregiver educational needs, in conjunction with the goal of effective, personalized health care. To serve as an expert primary care provider who coaches patients and caregivers toward positive behavioral change, primary care NPs need to demonstrate the use of information literacy skills in complex decision making. Exemplar 15-3 presents a situation in which technology and the use of the EHR enhance the care of a patient—that is, making timely consultation and referrals and consequently improving the outcomes of care for the patient. Their technology and information literacy competencies also inform NP contributions to the design of clinical information systems that promote safe, quality, and cost-effective care and enable NPs to use technology systems that capture data variables for the purpose of evaluating nursing care.

Policy Competencies

The evolution of advanced nursing practice has been influenced by changes in health care delivery and policy. APNs play an important role in providing direction for policy associated with primary care. Research has shown that nurses’ involvement in the decision making of health care organizations is crucial for maximizing positive health outcomes for clients (Mackay, 2002). The development of key leadership skills is essential for primary care NPs to become more critically aware of underlying power structures in the health care system and ultimately to move toward being acknowledged as interdependent health professionals in primary care organizations. To play such a role, primary care NPs need to understand the interdependence of policy and practice. They need to able to advocate for ethical policies that promote access, equity, quality, and affordability. Furthermore, they must analyze the ethical, legal, and social factors that influence policy development and contribute to the development of health policy. Finally, primary care NPs should be able to analyze the implications of health policy across disciplines and evaluate the impact of globalization on health care policy development.