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Effectiveness of registered nurses on system outcomes in primary care: a systematic review

Abstract

Background

Internationally, policy-makers and health administrators are seeking evidence to inform further integration and optimal utilization of registered nurses (RNs) within primary care teams. Although existing literature provides some information regarding RN contributions, further evidence on the impact of RNs towards quality and cost of care is necessary to demonstrate the contribution of this role on health system outcomes. In this study we synthesize international evidence on the effectiveness of RNs on care delivery and system-level outcomes in primary care.

Methods

A systematic review was conducted in accordance with Joanna Briggs Institute methodology. Searches were conducted in CINAHL, MEDLINE Complete, PsycINFO, and Embase for published literature and ProQuest Dissertations and Theses and MedNar for unpublished literature between 2019 and 2022 using relevant subject headings and keywords. Additional literature was identified through Google Scholar, websites, and reference lists of included articles. Studies were included if they measured effectiveness of a RN-led intervention (i.e., any care/activity performed by a primary care RN within the context of an independent or interdependent role) and reported outcomes of these interventions. Included studies were published in English; no date or location restrictions were applied. Risk of bias was assessed using the Integrated Quality Criteria for Review of Multiple Study Designs tool. Due to the heterogeneity of included studies, a narrative synthesis was undertaken.

Results

Seventeen articles were eligible for inclusion, with 11 examining system outcomes (e.g., cost, workload) and 15 reporting on outcomes related to care delivery (e.g., illness management, quality of smoking cessation support). The studies suggest that RN-led care may have an impact on outcomes, specifically in relation to the provision of medication management, patient triage, chronic disease management, sexual health, routine preventative care, health promotion/education, and self-management interventions (e.g. smoking cessation support).

Conclusions

The findings suggest that primary care RNs impact the delivery of quality primary care, and that RN-led care may complement and potentially enhance primary care delivered by other primary care providers. Ongoing evaluation in this area is important to further refine nursing scope of practice policy, determine the impact of RN-led care on outcomes, and inform improvements to primary care infrastructure and systems management to meet care needs.

Protocol registration ID

PROSPERO: International prospective register of systematic reviews. 2018. ID=CRD42018090767.

Peer Review reports

Background

Primary care providers are the first contact and principal point of continuing care for patients within the healthcare system, and coordinate other specialist care and services that patients may need [1, 2]. Primary care is commonly delivered in an office or clinic setting, with increasing virtual care options, by a team of healthcare providers that often include family physicians working alongside registered nurses (RNs), nurse practitioners, physician assistants, social workers, dieticians, or pharmacists [3, 4]. Team-based primary care, which is the delivery of health services by at least two healthcare providers who work collaboratively to accomplish shared goals with patients/caregivers, has the potential to improve quality, comprehensiveness, coordination, and effectiveness of care, as well as patient and provider satisfaction [5, 6]. The collaborative relationship between physicians and RNs is a key component in the delivery of primary care, with physician/RN teams well-positioned to influence positive outcomes for patients, families, and the healthcare system [7, 8].

Internationally, the primary care RN workforce is growing, but at a different pace across countries [9, 10]. In Australia, primary care nurse employment is increasing the fastest, with 63% of general practices employing a primary care nurse (82% of which are RNs) [11, 12]. In Canada, RNs make up about 70% of the primary care/community health nursing workforce [13]. Typically, RNs have completed either a college diploma or a baccalaureate degree and are able to care for patients with complex health needs who have unpredictable health outcomes. RNs have a more narrow scope of practice than nurse practitioners, and a wider scope of practice than licensed practical nurses (known as registered practical nurses in Ontario) [14]. In primary care settings, RNs function as generalists and provide a broad range of patient services, including preventative screening, health education and promotion, chronic disease prevention and management, acute episodic care, and a wide variety of therapeutic interventions [15,16,17,18]. Although job titles used to refer to RNs in primary care vary across countries, common titles include ‘family practice nurse’, ‘primary care nurse’, ‘general practice nurse’, and ‘primary health care nurse’ [19]. For the purpose of this paper, the term ‘primary care RN’ will be used hereafter when referring to this role. Internationally, policy-makers and health administrators are seeking evidence to inform further integration and optimal utilization of RNs within primary care teams [20, 21].

Recently, a systematic review conducted by Norful et al. [17] synthesized international literature related to primary care RNs and made recommendations for optimizing their roles within team-based primary care settings. This review included 18 studies from eight countries. Assessment, monitoring, and follow-up of patients with chronic diseases were identified as fundamental roles of the primary care RN [17]. In addition, countries such as Australia, Canada, New Zealand, and the United Kingdom have developed national standards of practice or defined competencies to articulate the unique roles of primary care RNs [13, 22,23,24,25,26]. Overall, the roles and activities of primary care RNs are becoming increasingly explored and understood internationally. However, the body of literature examining RN effectiveness in the primary care setting has not yet been synthesized. In general, research examining RN effectiveness has primarily been conducted within the acute care setting and focused on staffing, role enactment, and work environment. Within acute care, there is substantial evidence demonstrating the positive effects of the RN workforce on reducing adverse patient outcomes [27,28,29]. The ongoing evaluation and reporting of care delivered by primary care RNs is important to further refine nursing scope of practice policy, determine the impact of RN-led care on outcomes, and inform primary care infrastructure and systems management.

Theoretical foundation

The Nursing Role Effectiveness Model offers a framework to guide research examining nursing effectiveness (see Supplementary file 1). This model was developed based on the 1966 Donabedian [30] structure-process-outcome model of quality care and a literature review on nursing-sensitive outcomes and effectiveness of nursing interventions [31]. The structure component of the model consists of patient, nurse, and organizational variables that influence the roles and activities of RNs and outcomes of care [31]. The process component is focused exclusively on nursing interventions, which are treatments, procedures, or roles and actions that the nurse performs to enhance the patient’s health status or behaviour to move towards a desired outcome [32, 33]. The process component describes nurse activities according to three categories: independent, dependent, and interdependent [31, 34,35,36,37]. Independent roles are enacted by nurses autonomously, without physician oversight, and typically include assessment and surveillance (e.g., pain), triage, health promotion, risk factor screening, and the implementation of nursing interventions. In contrast, dependent roles describe activities that are part of an expanded nursing scope of practice and are conducted in response to physician medical orders, such as the implementation of medical treatments and prescribing of medications. Interdependent roles are activities nurses share with other members of the healthcare team, such as communication, consultations with other providers, and coordination of care. The Nursing Role Effectiveness Model allows for the conceptualization of the nursing contribution to outcomes of care, namely, functional health outcomes (e.g., physical, social, cognitive, mental functioning), self-care abilities, clinical outcomes (e.g., symptom control and management), prevention of adverse events (e.g., injury or nosocomial infections), patient’s knowledge and engagement (e.g., disease, treatments, management), patient satisfaction, and cost. A scoping review synthesized literature that has used the Nursing Role Effectiveness Model in all healthcare sectors to explore the applicability of using the model in primary care [37]. This review identified 22 articles that applied the model within their research framework. Eighteen of these studies were conducted in Canada or the United States, and 12 studies were focused on the acute care setting. To date, no known research has utilized this model to guide the evaluation of primary care RNs.

Purpose

Although existing literature provides some information about the contributions of RNs towards outcomes of care, a systematic review synthesizing the effectiveness of this important and growing role within team-based primary care settings is needed. The Cochrane Database of Systematic Reviews, the Joanna Briggs Institute (JBI) Library of Systematic Reviews, and the Prospective Register of Systematic Reviews (PROSPERO) were searched prior to commencement of this study and no registered protocols or previous systematic reviews on this topic were identified. Synthesizing evidence of primary care RNs on quality and cost of care is necessary to demonstrate the contribution of this nursing role and to inform decisions and policies that support the implementation and optimization of primary care RNs going forward [38, 39]. The purpose of this systematic review is to synthesize international evidence on care delivery and system outcomes of primary care RNs to support future best practices in care and research in this field.

Methods

Design

A systematic review was conducted using JBI Systematic Review Methodology [40] and findings were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) framework [41, 42] (the 2021 PRISMA guidelines were applied where possible). A systematic review approach was selected, given its utility for analyzing and synthesizing literature and evaluating outcomes [43]. Throughout each step of the review, Covidence software was used to efficiently manage and organize the literature [44] and enable a team approach for study and data review. The protocol for this systematic review is registered on PROSPERO (registration ID CRD42018090767). This paper presents findings from studies that report on care delivery and system outcomes. Findings from studies that measured patient outcomes are reported in the companion paper “Effectiveness of Registered Nurses on Patient Outcomes in Primary Care: A Systematic Review” [45].

Search strategy

The search strategy aimed to include both published and unpublished literature. A limited search of CINAHL and MEDLINE databases were conducted initially to identify optimal search terms and keywords by examining subject headings, titles, abstracts, and index terms of similar articles. Using identified targeted keywords and controlled vocabulary, we performed a comprehensive search of relevant electronic databases and grey literature (see Supplementary file 2). Applicable subject headings and keywords (e.g., “primary care”, “registered nurse”, “family practice”) were searched in CINAHL, MEDLINE Complete, PsycINFO (via EBSCOhost), and Embase (via embase.com) for published literature and ProQuest Dissertations and Theses and MedNar for unpublished literature. Unpublished literature was also identified using Google Scholar and the websites of relevant nursing organizations, such as the International Nursing Council, Canadian Family Practice Nurses Association, and Community Health Nurses of Canada. Reference lists of included articles were also searched to identify any additional studies. Database searches were conducted in January, 2019 and January, 2022 by a health sciences librarian (member of the study team); ongoing searches for grey literature included studies with publication dates up to January, 2022. Searches were limited to English-language citations, and no date limiters were applied.

Inclusion and exclusion criteria

The following pre-established article selection criteria were applied to the search strategy and screening process.

Inclusion criteria:

  • Studies that focused on RNs or equivalent. A recently completed review of international literature identified regulatory terms used to describe RNs working in primary care [19].

  • Studies that were conducted in a primary care setting.

  • Studies that measured outcomes attributable to a RN intervention.

  • Studies that used any quantitative design (e.g. randomized controlled trial, controlled before-after)

  • Studies that were published in English.

Exclusion criteria:

  • Studies that focused on advanced practice nurses, such as nurse practitioners.

  • Studies that did not specify regulatory nursing designation (e.g., referred to nursing in general).

  • Studies that were conducted in a setting other than primary care (e.g., acute care, specialist’s office)

  • Studies that did not examine a RN-led intervention (e.g., examined outcomes related to structural variables, such as staffing of RNs, in a practice).

  • Studies that required RNs to undergo considerable training in a particular area that went beyond the scope of generalist primary care practice (e.g., advanced training in the management of a specific disease, such as COPD).

According to the Nursing Role Effectiveness Model, nursing interventions are defined as “those that are relevant, based on nurses’ scope and domain of practice and for which there is empirical evidence linking nursing inputs and interventions to the outcomes” [47]. Outcomes of interest included, but were not limited to, those identified within the Nursing Role Effectiveness Model (e.g., functional status, patient satisfaction, cost, occurrence of adverse events such as falls or hospitalizations, clinical outcomes such as symptom frequency and severity) [31, 36, 37].

Screening

Prior to the title/abstract and full-text screening, an eligibility tool was developed by the research team outlining specific inclusion/exclusion criteria. A pilot screening was then conducted amongst three members of the research team, in which the same subset of titles/abstracts and full-text articles were screened independently. Discrepancies amongst reviewers were then discussed and the inclusion/exclusion tool was refined to increase clarity of the selection criteria. Based on best practice recommendations for systematic review screening, this process was repeated until all research team members applied the screening criteria consistently [46].

Covidence software facilitated a collaborative team approach to screening in which two authors (DR and JL) and two trained research assistants were involved. Following the initial pilot testing, all identified titles/abstracts were screened independently by two reviewers for potential study eligibility. Two reviewers then independently retrieved and screened full-text articles for relevancy, applying pre-established eligibility criteria. Any disagreements were resolved through discussion, or by a third reviewer.

Risk of bias

The risk of bias and quality of each study was assessed using the Integrated Quality Criteria for Review of Multiple Study Designs (ICROMS) tool [48], which is a comprehensive multi-design quality appraisal instrument. The ICROMS tool includes a list of quality criteria specific to each study design as well as a ‘decision matrix’, which specifies the minimum threshold that each study design needs to reach in order to be considered acceptably robust. The ICROMS tool scoring matrix was used to determine a quality score for each article (see scoring matrix located in Supplementary file 3). Following a pilot test, in which reviewers initially appraised 2–3 articles to increase comprehension of the tool and resolve any differences in assessment approaches, all full-text articles that met eligibility criteria were appraised for quality by two independent reviewers. The final scores were compared and discussed between both reviewers. Consensus on a final score was considered when both reviewers rated the quality within 2 points in either direction on the scoring matrix. All studies that met inclusion/exclusion criteria also met the minimum ICROMS score to be included in the review.

Data extraction and synthesis

All eligible full-text studies that met quality criteria underwent a data extraction procedure. The data extraction tool was designed prior to the start of the review by the research team and based on the Cochrane Public Health Group Data Extraction Template [49]. Two articles were selected at random and used to pilot test the tool by three members of the research team, during which time suggestions and alterations were made and a final draft was agreed upon. Data extracted from the articles included: country and year of publication, study aim, design, description of primary care setting, sample size, patient demographics, details of study intervention, RN involvement/role, description of outcome measures/data collection tools, and study results. Due to the heterogeneity of included studies, such as different methodologic approaches, study populations, interventions, and outcome measures, studies were synthesized in narrative format and studies that reported on similar outcomes were grouped together. To address the broad range of terms and descriptors used across included studies, (e.g., traditional care, standard care, basic support, care delivered by anyone other than a primary care RN), and to provide clarity in the presentation of our results, we refer to all control groups as “usual care” or the “comparator group”.

Results

After removal of duplicate articles, a total of 13,977 published titles and abstracts retrieved from database sources and 17 articles retrieved from grey literature sources were screened for relevancy, resulting in 272 full-text articles from database sources and 17 full-text articles from grey literature sources to undergo assessment by two independent reviewers. Following screening for eligibility and quality appraisal, data were extracted from a total of 29 studies, which were included in the final review (studies were only excluded based on eligibility criteria; none were excluded due to low quality). Fig. 1 presents a PRISMA diagram outlining the results of the literature search.

Fig. 1
figure 1

PRISMA Diagram of Literature Search

Study characteristics

Of the 29 articles included in the final review, 17 reported on care delivery and system outcomes (included in the present analysis) [45]. Table 1 presents a detailed summary of the study characteristics for each article reporting on care delivery and system outcomes (n = 17). Studies were published between the years 1996–2021. The majority of the studies were conducted in the United Kingdom (n = 8) and the United States (n = 5), with the remaining studies originating from Australia (n = 2) and New Zealand (n = 2). Study designs included randomized controlled trials (n = 9), quasi-experimental (no control/comparator group) (n = 5) (e.g., survey, cost-analysis), cohort (n = 1), non-controlled before-after (n = 1), and a mixed-methods design that included both quasi-experimental and non-controlled before-after (n = 1). Sample sizes ranged from 126 to 1906 patients. Quality scores, as assessed by the ICROMS tool, varied between studies. Three studies were scored at the minimum threshold for their study design [51, 57, 60], three studies scored 1–2 points above threshold [52, 53, 65], and eleven studies exceeded the minimum cut-off score by 3 or more points [50, 54,55,56, 58, 59, 61,62,63,64, 66].

Table 1 Literature Review Table of Study Characteristics (n = 17)

Overview of RN interventions

A variety of independent and interdependent RN interventions were examined across eligible studies. Most focused on some aspect of chronic disease prevention and management (n = 7) related to diabetes, coronary heart disease, and obesity [50, 52, 54, 60, 61, 64, 65]. Other RN interventions included smoking cessation support [56, 62], chlamydia screening, partner notification and treatment [51, 63], back pain education and management [53], telephone consultation/triage service [57], assessment of psychological distress [66], consultations aimed at increasing patient physical activity levels [58, 59], annual wellness visits [55], and laboratory monitoring [65]. Despite commonalities in study design and type of intervention delivered, strengths and limitations in scope and methodology varied across studies. Additional information regarding research limitations associated with each study are outlined in Supplementary file 4.

The majority of primary care RNs carried out the interventions independently, without a physician’s order or the support of other healthcare providers to respond to patient needs (n = 10) [51, 53,54,55,56, 58,59,60, 64, 66], while others carried out the intervention interdependently in association with other healthcare providers (e.g., physicians, health advisors, research assistant) (n = 6) [50, 52, 57, 62, 63, 65]. Another study examined the impact of varying levels of nursing involvement (low-level involvement versus high-level involvement) in general practices on patient obesity outcomes [61].

Of the studies included, five examined a RN-led intervention compared to the same intervention delivered by other healthcare providers [56, 60, 62,63,64], six studies compared RN-led interventions to ‘usual care’, defined as either care that existed prior to the intervention that did not involve a RN (n = 3) [50, 53, 59], or care associated with reduced or alternate levels of RN involvement (n = 3) [51, 52, 58], and one study compared a collaborative intervention involving primary care RNs supported by two different types of healthcare providers (clinical pharmacy specialists [CPS] and physicians) [65], where RNs assessed patients independently and presented the patient to either a CPS or a physician if hypertension continued to be poorly controlled). Lastly, five studies examined the effectiveness of a primary care RN intervention using a quasi-experimental design as a means of evaluation (i.e., no comparison group) [54, 55, 57, 61, 66].

Overview of outcomes

Table 2 presents a list of outcomes measured within included studies. Care delivery outcomes included quality and frequency of assessment and infection/disease screening (e.g., annual wellness visits, diabetic foot examinations, coronary heart disease, psychological disorders/distress, chlamydia), quality of smoking cessation support, appropriateness of laboratory monitoring, and quality of prescriptions issued/modified. System outcomes included cost, adverse health events, health service utilization, and changes in workload. A total of 15 care delivery outcomes (see Table 3) and 11 system outcomes (see Table 4) were identified across included studies.

Table 2 List of Outcomes Measured in Included Studies
Table 3 Literature Review Table – Care Delivery Outcomes
Table 4 Literature Review Table – System Outcomes

Care delivery outcomes

Quality of assessment and screening

Six studies examined the effectiveness of primary care RN-led assessment and screening. Three studies used a quasi-experimental design (no comparison group); one used patient questionnaires to assess the ability of primary care RNs to detect psychological distress [66], another implemented a cross-sectional survey of primary care RNs to evaluate trends in diabetes-related foot examinations [54], and another carried out a retrospective chart review to assess the impact of primary care RNs on preventative services performed during annual wellness visits [55]. Another study compared laboratory testing data before and after an intervention [51], and two conducted a randomized controlled trial in which RN-led care was examined against two comparator groups (i.e., ongoing physician support and usual care for follow-up of cardiovascular disease risk factors) [64] or usual care alone (standard protocol for partner notification after chlamydia diagnosis) [63]. According to these studies, improved assessment and prevention of coronary heart disease risk factors (i.e., blood pressure, cholesterol, smoking status) [64], adequate assessment of psychological distress levels [66], improved management of diabetic foot examinations [54], successful implementation of recommended preventative care services during annual wellness visits [55], and effective screening for sexually transmitted infection (e.g., chlamydia) [51, 63] can be provided by primary care RNs. Primary care RN-led screening for coronary heart disease risk factors was determined to be as effective as screening conducted by physicians (no significant difference found between groups) [64].

Quality of smoking cessation support

Two studies examined the quality of smoking cessation support delivered independently by primary care RNs versus medical assistants [56, 62], with one study offering an additional comparison to care provided by licensed practical nurses [62]. A secondary analysis of a previous randomized controlled trial from the United States found that medical assistants and licensed practical nurses were less likely to provide smoking cessation support in accordance with recommended clinical practice guidelines in comparison to primary care RNs. For instance, medical assistants and licensed practical nurses were less likely to assess willingness to quit smoking than primary care RNs (OR = 0.4; 95% CI: 0.2 to 0.8; p = 0.005 and OR = 0.5; 95% CI: 0.3 to 1.0; p = 0.03, respectively) [62]. A similar cohort study using longitudinal data from the United Kingdom determined that health care assistants took longer in their smoking cessation consultations with patients (24 min versus 21 min; p = 0.002) and provided the patient with more interim contacts (2 versus 1 contact; p < 0.001) in order to achieve equivalent outcomes. In this study, the type of smoking cessation provider (i.e., RN or health care assistant) seen by participants was not determined at random. While participants in each group had similar characteristics, there may have been unmeasured patient or provider cofounders that impacted findings [56].

Chlamydia case management

Azariah et al. [51] conducted an uncontrolled before-after pilot study of independent primary care RN-led opportunistic chlamydia testing in patients under 25-years of age and found improved case management, demonstrated by an increase in documentation of 1 week treatment follow-up and outcomes of partner notification in the Patient Management System. Similarly, a primary care RN-led strategy (with appropriate training) to improve partner notification for community diagnosed chlamydia patients was determined to be equally as effective as referral to a specialist health advisor at a genitourinary medicine clinic (47 versus 36 cases of at least one treated partner; OR = 12.4; 95% CI:-1.8 to 26.5; p = 0.087) [63].

Appropriate laboratory monitoring

Only one study in the review examined the appropriate ordering and follow-up of laboratory tests [65]. The authors defined appropriate laboratory monitoring as the ordering of a basic metabolic panel within 4 weeks of initiation or intensification of specific antihypertension agents (i.e., diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, aldosterone antagonists). A non-randomized, retrospective comparison of a natural experiment compared CPS-supported versus physician-supported primary care RN hypertension case management (RNs conducted assessment independently and involved CPS or a physician if hypertension was poorly controlled). Level of adherence to appropriate laboratory monitoring guidelines was assessed through review of laboratory results after the first patient appointment. The results indicated that laboratory monitoring within 4 weeks was completed in 7 out of 37 (19%) possible cases in the CPS-supported group and 14 out of 39 (36%) possible cases in the physician-supported group, with no significant differences between groups (p = 0.13). This demonstrates that primary care RN-CPS collaborative care teams can achieve equivalent outcomes to that of RN-physician teams. However, these findings may not accurately reflect the rate of laboratory tests ordered, as patients who were non-adherent to laboratory monitoring recommendations were excluded from the data analysis, limiting generalizability of the results.

Access to appropriate medications (illness management)

Three studies explored primary care RN-led or facilitated illness management, specifically with respect to prescription medication strategies [57, 64, 65]. Gallagher et al. [57] determined the impact of telephone triage conducted independently by a primary care RN on the management of same day requests for consultations. Fifty-one percent (n = 647/1262) of the consultations resulted in new or changed prescriptions. The authors concluded that primary care RN triage enhanced efficiency of the practice and allowed for timely medication management. Moher et al. [64], using a cluster randomized controlled trial approach, explored the effectiveness of three interventions (audit and feedback, recall to a physician, recall to a primary care RN clinic) for improving secondary preventive care of patients with coronary heart disease. One of the targeted outcomes was the use of hypotensive, lipid lowering, and anti-platelet drug management. Prescribing of hypotensive and lipid lowering medications was similar between groups, however, prescribing of antiplatelet drugs revealed a small significant difference between the primary care RN recall group and the audit group (10% difference; 95% CI: 3 to 17%; p = 0.009), and between the primary care RN recall group and the physician recall group (8% difference; 95% CI: 1 to 15%; p = 0.031). O’Neill et al. [65], using a retrospective comparison, compared CPS-supported versus physician-supported primary care RN case management on the optimization of medication management for patients with uncontrolled hypertension using data available within existing electronic clinical records (i.e. clinical progress notes). Medication intensification at the index visit was similar between groups (no significant difference), supporting the use of collaborative teams, consisting of either CPS-or physician-supported primary care RN case management.

System outcomes

Adverse events

Three studies examined adverse events in usual care that did not involve care delivered by a RN versus primary care RN-led interventions for diabetes (i.e., randomized controlled trial examining nurse case management for diabetes control) [50] and physical activity (i.e., clustered randomized controlled trial examining a RN-supported pedometer intervention) [58, 59]. Adverse events measured in these studies consisted of falls, injuries, cardiovascular events, episodes of severe hypoglycemia, emergency room visits and hospital admissions, deaths, and any deterioration of a pre-existing health problem. Two studies found no significant differences between the intervention and usual care groups [50, 58], while the third study found no difference in total adverse events at 3 and 12 months, but a significantly lower number of adverse cardiovascular events over the 12-month study period (p = 0.04) for the intervention group [59]. All three of these studies examined a unique role of the RN in supporting diabetes and promoting physical activity, limiting the generalizability of these findings to routine primary care practice.

Service utilization

A randomized controlled trial evaluating the impact of an educational intervention for low back pain [53] found no difference in the frequency of clinic visitations for patients who received primary care RN-delivered care versus usual care with the provision of an educational booklet (p = 0.7) or usual care alone (no educational booklet or primary care RN educational sessions) (p = 0.7). A study examining the effectiveness of primary care RN-led telephone triage for patients seeking a same-day appointment found that repeat consultations for the same problem after 1 week were significantly higher for patients who were triaged to primary care RN consultations than physician consultations (52% versus 37%; 95% CI: 2 to 28%; p = 0.02) [57]. However, this study did not assess whether the repeat visit indicated that patient problems were dealt with inadequately at triage.

Workload

Primary care RN-led telephone triage of patients seeking a same-day appointment reduced physician visits by 54% (1522 to 664) and primary care RN visits by 21% (1793 to 1415) [57]. However, it is unclear whether or not this decrease in workload was attributable to the intervention or seasonality, as the study compared the intervention period with the 3-month period prior to intervention, rather than with a 3-month period from the same season (i.e., summer) in the previous year. A study of a primary care RN-led model of chronic disease management within a general practice found that the primary care RN-led model of care did not significantly decrease the total number of physician visits, as the total visits per patient more than doubled during the intervention period for all three chronic diseases (type 2 diabetes, cardiovascular disease, hypertension), disputing the notion that the RN-led model of care would free up physician workload [60].

Cost

Four studies examined costs associated with primary care RN-led interventions. An Australian costing study found that the costs associated with primary care RNs in general practice clinics could be covered by the additional Medicare Benefit Schedule (MBS) billings generated from the primary care RNs [60]. It should be noted that costing studies describe costs of an intervention (i.e., employing primary care RNs) without considering the health effects of the intervention [67, 68].

Cost-effectiveness studies compare costs of an intervention relative to health effects of the intervention [67, 68]. Karnon et al. [61] compared the costs of primary care RN-led obesity interventions in clinics with high versus low-level involvement of primary care RNs in the clinic. The marginal incremental cost of high-level clinics was $563 (95% CI: $123 to $1547) per one point reduction of body mass index (BMI). The high-level clinics produced a statistically significant reduction in mean BMI compared to low-level clinics, but the total reduction in weight was not clinically significant. The study was unable to compare the intervention to usual care. Another cost-effectiveness study, conducted by Low et al. [63], found that the costs and effects (number of sexual partners treated for chlamydia) did not significantly differ for the primary care RN-led intervention versus usual care in reference to rate of partner notification (mean unit cost = £11.72; 95% CI: 10.37 to 13.08 versus £10.86; 95% CI: 9.74 to 11.98, respectively) or for partner treatment (mean unit cost = £32.55; 95% CI: 31.20 to 33.91 versus £32.62; 95% CI: 31.49 to 33.73, respectively).

Cost utility analyses calculate the costs of the intervention relative to the quality of life changes stemming from the effects of the interventions [67, 68]. Bellary et al. [52] calculated the incremental cost-effectiveness ratio of £28,933 per quality-adjusted life-year (QALY) gained and concluded that the cost needed to fund the primary care RN-led culturally sensitive diabetes intervention over a 2-year period did not produce significant improvements in patient quality of life, given the modest or non-significant differences in clinical outcomes. However, this study focused on a specific patient population (i.e., adult patients of South Asian origin with type 2 diabetes) and findings are based on clinical biomarker changes (i.e., blood pressure, total cholesterol) as the sole measurement of patient quality of life, which ignores elements of the patient experience and other measures that contribute to a more fulsome quality of life measurement.

Discussion

This systematic review presents synthesized evidence on care delivery and system outcomes by primary care RNs. Overall, the findings indicate that primary care RNs have an impact on the delivery of appropriate, high-quality care that meet patient needs and that RN care can be tailored to specific health conditions, including diabetes, sexually transmitted infections, coronary heart disease, and obesity. Similarly, findings demonstrate that primary care RNs can be effective in the implementation of preventative screening services and the promotion of health behaviors, such as smoking cessation consultations and diabetic foot care education. The studies included in this review captured many variables included in the Nursing Role Effectiveness Model, including independent and interdependent interventions and care delivery (e.g., quality of assessment, screening, and disease management) and system outcomes. Prevention of adverse events is an important component of nursing care and includes the promotion of patient safety and freedom from injury/infection [31]. Likewise, cost outcomes identified in the model may include any direct or indirect costs associated with nursing care and nursing interventions (e.g., health service utilization) [31, 35]. These components of the framework were measured in several studies included in this review. The identification of other outcomes not listed in the Nursing Roles Effectiveness Model could potentially inform a modification of the Nursing Role Effectiveness Model tailored specifically to the primary care setting and roles that RNs commonly perform. Furthermore, although the Nursing Role Effectiveness Model served as a guide to map study variables, many studies did not consider the structural component of the model (e.g., nurse characteristics, such as level of education, years of experience, context of care) which may have impacted outcomes observed or did not always describe specific interventions in detail.

The studies suggest that RN-led care may have an impact on care delivery and system outcomes, specifically in relation to the provision of medication management, patient triage, chronic disease prevention and management, treatment of acute illnesses/conditions, educational interventions, sexual health, health promotion, and self-management interventions, such as smoking cessation support and promotion of physical activity. In particular, there is growing literature demonstrating the benefits (e.g., improved access to medications, physician support) of non-physician prescribing, which involves nurses, pharmacists, and physician assistants substituting for physicians in a prescribing role [69,70,71]. Specifically, RN prescribing is increasingly recognized as an emerging role within primary care [72, 73]. It is also within the current scope of practice of RNs, regardless of their competencies or education level, to recommend over-the-counter medications to alleviate symptoms or treat minor/acute illnesses, suggest and titrate dosages, discuss medication administration routes, educate patients on the side-effects of medication and drug-drug interactions, and perform medication list reviews [69, 74,75,76]. Weeks et al. [71] conducted a systematic review that assessed outcomes of non-medical prescribing for managing acute and chronic health conditions in primary and secondary care settings compared with medical prescribing (usual care). Twenty-six studies included in the review reported on outcomes related to non-medical prescribing undertaken by nurses in general (but did not differentiate between nursing provider types). Overall, the findings suggested that non-medical prescribers were as effective as usual care medical prescribers, and that regulators and health administrators should explore this expanded role for RNs as an opportunity to improve medication access and address unmet health needs.

Although this study provides preliminary evidence on outcomes of RNs in primary care with regards to medication management, triage, chronic disease management, sexual health, and health promotion/self-management interventions, the included studies did not capture outcomes related to the many other roles/activities performed by RNs within this setting. Primary care RNs function as generalists who provide a broad range of services. Common roles/activities performed by primary care RNs that were not captured in the studies included in this review are therapeutic interventions (e.g., wound care, treatment of infections), pediatric and women’s health, health prevention and public health services (e.g., immunizations), and care/case coordination (nursing surveillance, professional referral, system navigation). Furthermore, while this study provides preliminary evidence on the effectiveness of RN-led interventions in primary care, research demonstrating the long-term impacts of these interventions is lacking. The lack of longitudinal research does not allow for conclusions to be drawn regarding the long-term impacts of RN interventions (e.g., health promotion, nursing surveillance) on patient morbidity and mortality. High-quality longitudinal research involving the use of a cohort design or analysis of large datasets is needed to explore the effectiveness of primary care RNs over time. The absence of large databases capturing nursing interventions is hindering progress in this field of research. Lastly, the overarching competencies (i.e., integrated knowledge, skills, judgement, and attributes) that guide primary care RN practice include leadership, communication, and collaboration and partnership with other healthcare providers; these competencies, which are also represented in the Nursing Role Effectiveness Model, have yet to be evaluated in the primary care RN literature.

There have been few studies to examine the cost of nursing within any professional designation (i.e., RN, nurse practitioner, licensed practical nurse) in primary care internationally. This review identified only four studies that reported on cost outcomes for RNs in primary care, with substantial variability across studies, limiting the ability to make comparisons and draw firm conclusions. The included studies also did not account for context of care or indirect cost savings from RN contributions (e.g., savings in physician costs). In addition, the financial impact and cost reduction associated with long-term health prevention is difficult to measure and capture in the literature because cohort studies are difficult to conduct in a primary care setting. In contrast, there is increased evidence of the added value of nurse practitioners, more specifically improved clinical outcomes and patient and provider satisfaction, through several randomized controlled trials and systematic reviews [77]. However, due to limitations and challenges with economic evaluations, the question of cost-effectiveness of RNs and nurse practitioners in primary care remains [77]. Notably, economic evaluations of nursing interventions often do not consider or adequately capture the importance of patient-relevant outcomes (e.g., patient satisfaction, patient knowledge, treatment adherence and self-management, health-related quality of life, and patient self-reported physical, mental, and social functioning) [77] or primary care RN contributions to other domains of practice that contribute to optimal health outcomes [7, 77, 78]. In order to provide a more comprehensive economic evaluation, all elements of RN care provision within primary care need to be taken into account, such as context of practice (e.g., team-based settings, remuneration, nurse characteristics), scope of practice, and robust methodologies that employ adequate comparator groups.

While all studies met minimum quality thresholds to be included in this review, a number of methodological issues remain. Many studies in the review tend to be limited to outcomes involving direct patient care, therefore overlooking the multidimensional nature of primary care RN competencies that includes contributions towards other domains of practice, such as quality improvement, research, education, collaboration and partnership, and leadership activities, that also contribute to health and well-being of patients and families [7, 77, 78]. Additionally, there were only 12 studies that employed a design with a control/comparator group (the other studies were quasi-experimental/observational in nature). Choosing an appropriate comparator can present a challenge, as ‘usual care’ is often not well-defined and may be unique to a specific type or model of care (e.g., team-based care, nurse-led) or jurisdiction, making it difficult to apply results on a broader scale [77, 79]. Within the primary care setting, there are also many challenges associated with isolating and measuring the impact of individual health providers within the context of a team, such as the complex nature of roles and variability in practice settings. For example, many studies specific to primary care RNs focus on interdependent roles within broader healthcare teams, which often involves the shifting of work from one provider to another (e.g., physician to a RN) or care provided in collaboration with another team member [77, 79]. Additionally, studies must address role-specific considerations, such as differentiating between interdependent and independent activities within the primary care setting.

Strengths and limitations

Strengths of this systematic review include the application of a comprehensive search strategy, use of the PRISMA checklist in planning and reporting, and appraisal using an established quality assessment tool (i.e., ICROMS). However, despite utilizing a comprehensive search strategy, it is possible that not all relevant studies were retrieved and included in this review. This review exclusively examined studies in which an intervention was delivered by a RN. In many cases, the RN designation was not stated or could not be clearly determined, therefore resulting in exclusion from the review. The lack of consistent terminology and available data regarding terminology used to describe RNs, or equivalent nursing titles, across countries limited the ability to include studies published in certain regions; however, we did attempt to compensate for the variation in terminology in our search mesh terms. Only studies published in the English language were included, which may limit generalizability to certain countries and exclude potential findings published in other languages. Furthermore, we identified four economic evaluations of RNs in primary care using the search strategy. Further research specifically targeting economic evaluations is needed to fully assess the cost implications of primary care RNs. Due to the limited number of high-quality randomized controlled trials, which provide the strongest level of evidence, the generalizability of findings from this study are limited. Similarly, the generalizability of the findings are further limited by the inclusion of a broad range of study designs, RN-led interventions (which were delivered independently by the RN or in collaboration with other providers and included different comparison/control groups), and outcome measures. Due to this diversity, meta-analysis was not possible and the findings should be interpreted with caution.

Conclusions

Primary care RNs are increasingly becoming embedded into the core of interprofessional primary care teams [3, 4]. Overall, the findings suggest that primary care RNs impact the delivery of quality primary care, and that RN-led care may complement and potentially enhance primary care delivered by other primary care providers. RNs can provide appropriate, high quality primary care services, including but not limited to, medication management, patient triage, chronic disease prevention and management, treatment of acute illnesses/conditions, educational interventions, health promotion, and management interventions. Greater resources need to be directed towards evaluating the contribution of this unique role in primary care in order to optimize and strengthen the delivery of patient-focused care. Findings from this review can inform further integration and optimization of this role, are applicable to researchers and other stakeholders engaged in primary care interventions, and can assist with future evaluations and the development of more efficient primary care services. As increasing numbers of RNs are employed in primary care, more rigorous approaches to research employing robust study designs needs to be conducted to further understand the impact of RNs on care delivery and system outcomes in primary care.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Abbreviations

RN:

Registered Nurse

JBI:

Joanna Briggs Institute

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

PROSPERO:

Prospective Register of Systematic Reviews

ICROMS:

Integrated Quality Criteria for Review of Multiple Study Designs

CI:

Confidence Interval

OR:

Odds Ratio

CPS:

Clinical Pharmacy Specialist

MBS:

Medicare Benefits Schedule

BMI:

Body Mass Index

HbA1C:

Hemoglobin A1C

QALY:

Quality-Adjusted Life-Year

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Acknowledgements

We acknowledge the following research assistants for the contributions to the systematic review screening, appraisal and data extraction process: Richard Buote, Ashley Joyce, Olivia Parsons, and Arifur Rahman.

Funding

This research was supported by funding received from Memorial University and the Department of Health & Community Services, Government of Newfoundland & Labrador.

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JL conceptualized the larger project, obtained grant funding, supervised data collection and screening, interpreted and synthesized results, and drafted and revised the manuscript; SA, EGM, MM, JT interpreted results and drafted and revised the manuscript; MS carried out the initial search strategy, assisted with adherence to PRISMA guidelines, interpreted results, and drafted and revised the manuscript; DBL, RMM, AN, MEP interpreted results and revised the manuscript; DR screened, appraised and extracted data, and assisted with interpretation of results and the drafting/revising of the manuscript. All authors approved the final draft.

Corresponding author

Correspondence to Julia Lukewich.

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Lukewich, J., Asghari, S., Marshall, E.G. et al. Effectiveness of registered nurses on system outcomes in primary care: a systematic review. BMC Health Serv Res 22, 440 (2022). https://doi.org/10.1186/s12913-022-07662-7

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  • DOI: https://doi.org/10.1186/s12913-022-07662-7

Keywords

  • Effectiveness
  • Primary healthcare
  • Registered nurse
  • Primary care nursing
  • Systematic review
  • Outcomes
  • Care delivery