dokumen.pub_primary-care-the-art-and-science-of-advanced-practice-nursing-an-interprofessional-approach-6nbsped-1719644659
Chapter 1
Primary Care in the Twenty-First
Century:
A Circle of Caring
Jill E. Winland-Brown, EdD, APRN, FNP-BC, FAANP
Lynne M. Dunphy, PhD, APRN, FNP-BC, FAAN, FAANP
Debera J. Thomas, PhD, RN, ANP/FNP
Brian Oscar Porter, MD, PhD, MPH, MBA
Because advanced practice nurses comprise much of the primary health-care
workforce, they are in an ideal situation to bring the caring “piece” into
advanced practice primary care nursing. As this chapter will illustrate, the art
of caring in practice is an essential element for improving the health of the
nation.
Because advanced practice nurses comprise much of the primary health-care
workforce, they are in an ideal situation to bring the caring “piece” into
advanced practice primary care nursing. As this chapter will illustrate, the art
of caring in practice is an essential element for improving the health of the
nation.
WHERE WE ARE AND WHERE WE ARE
GOING
Our health-care system is in flux, as issues of systemic racism and recovery
from the COVID-19 pandemic dominate the national agenda and as political
battles over health-care funding shift rapidly. Educational models are also in
,dokumen.pub_primary-care-the-art-and-science-of-advanced-practice-nursing-an-interprofessional-approach-6nbsped-1719644659
the process of being reformed; interprofessional education and team-based
care are required norms, and clinical education is moving increasingly toward
competency-based assessments and curricula. It “takes a village” to provide
quality, cost-effective, population-based, and person-centered primary care.
This book is dedicated to the notion that advanced practice registered nurses
(APRNs), specifically primary care nurse practitioners (NPs), are ideal care
providers to take a leadership role in our continually evolving health-care
delivery system, especially in safety net settings, such as federally qualified
health centers.
This chapter describes the disciplines of nursing and medicine,
highlighting the different strengths that each disciplinary background brings
to the care of patients. The Circle of Caring practice model on which this text
is based is presented as a way of making primary care practice, which
incorporates aspects of what has been traditionally defined as medical
practice, richer by integrating nursing-based understanding of the lived
experiences of patients and families in the context of community and caring
relationships.
The Future of Nursing Reports
Heeding the recommendation of the initial Institute of Medicine’s (IOM)
report The Future of Nursing: Leading Change, Advancing Health (2011)
that all nurses practice to their full scope of education, many states have
implemented important changes in APRN scope of practice regulations.
Nonetheless, the scope of practice for APRNs remains inconsistent across the
United States, and APRN autonomy faces persistent threats, even though
certain practice restrictions were lifted during the COVID-19 pandemic,
starting in 2020.
The second IOM report in 2016, Assessing Progress on the Future of
Nursing, found that there was much more to be done and suggested three
themes necessary for future success: 1) the need for nurses to play a full role
in practice, education, collaboration, and leadership; 2) the need for diversity
in the nursing workforce; and 3) the need for better data to evaluate progress.
The third report, The Future of Nursing 2020-2030: Charting a Path to
Achieve Health Equity (2021) (Box 1.1), continues to advocate for full
practice authority for APRNs, as well as major changes to the structure of our
health-care system to improve the culture of health for all. With nurses
experiencing first-hand the inequitable impact of the COVID-19 pandemic’s
,dokumen.pub_primary-care-the-art-and-science-of-advanced-practice-nursing-an-interprofessional-approach-6nbsped-1719644659
effects on the United States, they have stepped up to address these inequities.
As this report highlights, the COVID-19 pandemic has taught us that the
American health-care system continues to struggle with fiscal realities, as
well as questions of quality, health-care disparities, structural racism, access
to care, and potential burnout of the primary care workforce. Emerging
pandemics (as illustrated by COVID-19), technological advances, an aging
population, chronic illnesses, and alarming increases in behavioral health
issues, such as those manifested by the U.S. opioid epidemic and ever-
increasing gun violence, color the ongoing political debate over the American
health-care system, as politicians and the public debate whether health care is
a right or a privilege. For example, the Affordable Care Act of 2010, which
was rejuvenated in 2021 under the Biden administration, has achieved major
reforms, despite ongoing political, legal, and policy efforts to dismantle it.
Within the context of legislative initiatives, payment reform has continued to
evolve from a fee-for-service payment system to payment for quality, cost,
and satisfaction with care (see Chapter 86). However, illnesses often continue
to be treated episodically, outside the context of home, family, community,
and people’s day-to-day lives, in isolation from the trajectory of individuals’
lives.
Box 1.1 The Future of Nursing 2020-2030: Charting a
Path to Achieve Health Quality
Recommendation 1:
In 2021, all national nursing organizations should initiate work to develop a shared agenda
for addressing social determinants of health and achieving health equity. This agenda
should include explicit priorities across nursing practice, education, leadership, and health
policy engagement. The Tri-Council for Nursing and the Council of Public Health Nursing
Organizations, with their associated member organizations, should work collaboratively and
leverage their respective expertise in leading this agenda-setting process. Relevant
expertise should be identified and shared across national nursing organizations, including
the Federal Nursing Service Council and the National Coalition of Ethnic Minority Nurse
Associations. With support from the government, taxpayers, health and health-care
organizations, and foundations, the implementation of this agenda should include associated
timelines and metrics for measuring impact.
Recommendation 2:
By 2023, state and federal government agencies, health-care and public health
organizations, taxpayers, and foundations should initiate substantive actions to enable the
nursing workforce to address social determinants of health and health equity more
comprehensively, regardless of practice setting.
, dokumen.pub_primary-care-the-art-and-science-of-advanced-practice-nursing-an-interprofessional-approach-6nbsped-1719644659
Recommendation 3:
By 2021, nursing education programs, employers, nursing leaders, licensing boards, and
nursing organizations should initiate the implementation of structures, systems, and
evidence-based interventions to promote nurses’ health and well-being, especially as they
take on new roles to advance health equity.
Recommendation 4:
All organizations, including state and federal entities and employing organizations, should
enable nurses to practice to the full extent of their education and training by removing
barriers that prevent them from more fully addressing social needs and social determinants
of health and by improving health-care access, quality, and value. These barriers include
regulatory and public and private payment limitations; restrictive policies and practices; and
other legal, professional, and commercial impediments. The term “commercial” refers to
contractual agreements and customary practices that make antiquated or unjustifiable
assumptions about nursing.
Recommendation 5:
Federal, tribal, state, local, and private payers and public health agencies should establish
sustainable and flexible payment mechanisms to support nurses in both health care and
public health, including school nurses, in addressing social needs, social determinants of
health, and health equity.
Recommendation 6:
All public and private health-care systems should incorporate nursing expertise in designing,
generating, analyzing, and applying data to support initiatives focused on social
determinants of health and health equity, using diverse digital platforms, artificial
intelligence, and other innovative technologies.
Recommendation 7:
Nursing education programs, including continuing education, and accreditors and the
National Council of State Boards of Nursing should ensure that nurses are prepared to
address social determinants of health and achieve health equity.
Recommendation 8:
To enable nurses to address inequities within communities, federal agencies and other key
stakeholders within and outside the nursing profession should strengthen and protect the
nursing workforce during the response to such public health emergencies as the COVID-19
pandemic and natural disasters, including those related to climate change.
Recommendation 9:
The National Institutes of Health, the Centers for Medicare & Medicaid Services, the Centers
for Disease Control and Prevention, the Health Resources and Services Administration, the
Agency for Healthcare Research and Quality, the Administration for Children and Families,
the Administration for Community Living, and private associations and foundations should
convene representatives from nursing, public health, and health care to develop and support
a research agenda and evidence base describing the impact of nursing interventions,
including multisector collaboration, on social determinants of health, environmental health,
health equity, and nurses’ health and well-being.
Source: National Academies of Sciences, Engineering, and Medicine (2021). The Future of
Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The
Chapter 1
Primary Care in the Twenty-First
Century:
A Circle of Caring
Jill E. Winland-Brown, EdD, APRN, FNP-BC, FAANP
Lynne M. Dunphy, PhD, APRN, FNP-BC, FAAN, FAANP
Debera J. Thomas, PhD, RN, ANP/FNP
Brian Oscar Porter, MD, PhD, MPH, MBA
Because advanced practice nurses comprise much of the primary health-care
workforce, they are in an ideal situation to bring the caring “piece” into
advanced practice primary care nursing. As this chapter will illustrate, the art
of caring in practice is an essential element for improving the health of the
nation.
Because advanced practice nurses comprise much of the primary health-care
workforce, they are in an ideal situation to bring the caring “piece” into
advanced practice primary care nursing. As this chapter will illustrate, the art
of caring in practice is an essential element for improving the health of the
nation.
WHERE WE ARE AND WHERE WE ARE
GOING
Our health-care system is in flux, as issues of systemic racism and recovery
from the COVID-19 pandemic dominate the national agenda and as political
battles over health-care funding shift rapidly. Educational models are also in
,dokumen.pub_primary-care-the-art-and-science-of-advanced-practice-nursing-an-interprofessional-approach-6nbsped-1719644659
the process of being reformed; interprofessional education and team-based
care are required norms, and clinical education is moving increasingly toward
competency-based assessments and curricula. It “takes a village” to provide
quality, cost-effective, population-based, and person-centered primary care.
This book is dedicated to the notion that advanced practice registered nurses
(APRNs), specifically primary care nurse practitioners (NPs), are ideal care
providers to take a leadership role in our continually evolving health-care
delivery system, especially in safety net settings, such as federally qualified
health centers.
This chapter describes the disciplines of nursing and medicine,
highlighting the different strengths that each disciplinary background brings
to the care of patients. The Circle of Caring practice model on which this text
is based is presented as a way of making primary care practice, which
incorporates aspects of what has been traditionally defined as medical
practice, richer by integrating nursing-based understanding of the lived
experiences of patients and families in the context of community and caring
relationships.
The Future of Nursing Reports
Heeding the recommendation of the initial Institute of Medicine’s (IOM)
report The Future of Nursing: Leading Change, Advancing Health (2011)
that all nurses practice to their full scope of education, many states have
implemented important changes in APRN scope of practice regulations.
Nonetheless, the scope of practice for APRNs remains inconsistent across the
United States, and APRN autonomy faces persistent threats, even though
certain practice restrictions were lifted during the COVID-19 pandemic,
starting in 2020.
The second IOM report in 2016, Assessing Progress on the Future of
Nursing, found that there was much more to be done and suggested three
themes necessary for future success: 1) the need for nurses to play a full role
in practice, education, collaboration, and leadership; 2) the need for diversity
in the nursing workforce; and 3) the need for better data to evaluate progress.
The third report, The Future of Nursing 2020-2030: Charting a Path to
Achieve Health Equity (2021) (Box 1.1), continues to advocate for full
practice authority for APRNs, as well as major changes to the structure of our
health-care system to improve the culture of health for all. With nurses
experiencing first-hand the inequitable impact of the COVID-19 pandemic’s
,dokumen.pub_primary-care-the-art-and-science-of-advanced-practice-nursing-an-interprofessional-approach-6nbsped-1719644659
effects on the United States, they have stepped up to address these inequities.
As this report highlights, the COVID-19 pandemic has taught us that the
American health-care system continues to struggle with fiscal realities, as
well as questions of quality, health-care disparities, structural racism, access
to care, and potential burnout of the primary care workforce. Emerging
pandemics (as illustrated by COVID-19), technological advances, an aging
population, chronic illnesses, and alarming increases in behavioral health
issues, such as those manifested by the U.S. opioid epidemic and ever-
increasing gun violence, color the ongoing political debate over the American
health-care system, as politicians and the public debate whether health care is
a right or a privilege. For example, the Affordable Care Act of 2010, which
was rejuvenated in 2021 under the Biden administration, has achieved major
reforms, despite ongoing political, legal, and policy efforts to dismantle it.
Within the context of legislative initiatives, payment reform has continued to
evolve from a fee-for-service payment system to payment for quality, cost,
and satisfaction with care (see Chapter 86). However, illnesses often continue
to be treated episodically, outside the context of home, family, community,
and people’s day-to-day lives, in isolation from the trajectory of individuals’
lives.
Box 1.1 The Future of Nursing 2020-2030: Charting a
Path to Achieve Health Quality
Recommendation 1:
In 2021, all national nursing organizations should initiate work to develop a shared agenda
for addressing social determinants of health and achieving health equity. This agenda
should include explicit priorities across nursing practice, education, leadership, and health
policy engagement. The Tri-Council for Nursing and the Council of Public Health Nursing
Organizations, with their associated member organizations, should work collaboratively and
leverage their respective expertise in leading this agenda-setting process. Relevant
expertise should be identified and shared across national nursing organizations, including
the Federal Nursing Service Council and the National Coalition of Ethnic Minority Nurse
Associations. With support from the government, taxpayers, health and health-care
organizations, and foundations, the implementation of this agenda should include associated
timelines and metrics for measuring impact.
Recommendation 2:
By 2023, state and federal government agencies, health-care and public health
organizations, taxpayers, and foundations should initiate substantive actions to enable the
nursing workforce to address social determinants of health and health equity more
comprehensively, regardless of practice setting.
, dokumen.pub_primary-care-the-art-and-science-of-advanced-practice-nursing-an-interprofessional-approach-6nbsped-1719644659
Recommendation 3:
By 2021, nursing education programs, employers, nursing leaders, licensing boards, and
nursing organizations should initiate the implementation of structures, systems, and
evidence-based interventions to promote nurses’ health and well-being, especially as they
take on new roles to advance health equity.
Recommendation 4:
All organizations, including state and federal entities and employing organizations, should
enable nurses to practice to the full extent of their education and training by removing
barriers that prevent them from more fully addressing social needs and social determinants
of health and by improving health-care access, quality, and value. These barriers include
regulatory and public and private payment limitations; restrictive policies and practices; and
other legal, professional, and commercial impediments. The term “commercial” refers to
contractual agreements and customary practices that make antiquated or unjustifiable
assumptions about nursing.
Recommendation 5:
Federal, tribal, state, local, and private payers and public health agencies should establish
sustainable and flexible payment mechanisms to support nurses in both health care and
public health, including school nurses, in addressing social needs, social determinants of
health, and health equity.
Recommendation 6:
All public and private health-care systems should incorporate nursing expertise in designing,
generating, analyzing, and applying data to support initiatives focused on social
determinants of health and health equity, using diverse digital platforms, artificial
intelligence, and other innovative technologies.
Recommendation 7:
Nursing education programs, including continuing education, and accreditors and the
National Council of State Boards of Nursing should ensure that nurses are prepared to
address social determinants of health and achieve health equity.
Recommendation 8:
To enable nurses to address inequities within communities, federal agencies and other key
stakeholders within and outside the nursing profession should strengthen and protect the
nursing workforce during the response to such public health emergencies as the COVID-19
pandemic and natural disasters, including those related to climate change.
Recommendation 9:
The National Institutes of Health, the Centers for Medicare & Medicaid Services, the Centers
for Disease Control and Prevention, the Health Resources and Services Administration, the
Agency for Healthcare Research and Quality, the Administration for Children and Families,
the Administration for Community Living, and private associations and foundations should
convene representatives from nursing, public health, and health care to develop and support
a research agenda and evidence base describing the impact of nursing interventions,
including multisector collaboration, on social determinants of health, environmental health,
health equity, and nurses’ health and well-being.
Source: National Academies of Sciences, Engineering, and Medicine (2021). The Future of
Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The
