Editorial - (2015) Volume 23, Issue 3
Associate Professor, George Mason University, USA
There is unprecedented agreement on the need to make primary care a greater part of the health care system. Despite steps taken by the Affordable Care Act to support the provision of primary care, the shortage of primary care providers is projected to worsen in the United States in the coming years.[1,2] The Institute of Medicine (IOM) report , The Future of Nursing: Leading Change Advancing Health, makes it clear that advanced practice registered nurses (APRNs) are key to providing high quality healthcare; poised to help bridge the gap between coverage and access; able to coordinate increasingly complex care for a wide range of patients; and able to fulfill their potential as primary care providers to the full extent of their education and training.[3]
However, the health professions like – medicine, dentistry, nursing, pharmacy, physical therapy, occupational therapy– are primarily focused on individuals. Nurses have not only been educated with a focus on individuals but the vast majority of nurses entering advance nurse practice programs come from clinical practice facilities such a hospitals and outpatient services, that also focus, almost exclusively, on the individual. So the challenge is how best to integrate a broader perspective into existing educational curriculum. Courses in community-oriented primary care and health policy alone will not ensure the best preparation of APRNs who will enter the primary care workforce. The entire curriculum must promote better understanding of the social determinants of health and effectively blend the individual and population perspective in all clinical and non-clinical courses.
This recommendation is certainly in line with a recent report of the Robert Woods Johnson Foundation (RWJ) that calls for “a paradigm shift across providers towards primary care that is proactive, oriented to communities and individuals, comprehensive, participatory and linked with other services and activities that improve population health. This implies building a culture of health, involving people in contributing to improvements in health and wellbeing.”[4] Advanced Practice Registered Nurses must not only hone their clinical skills but their public health skills as well. So APRNs must understand, as the RWJ Foundation further suggests, the conditions in neighborhoods and communities that harm the health of populations, trigger unhealthy or risky behaviors and undermine the success of communities and the importance of policies that address early child care, housing, transportation, food security, unemployment, and economic development, to name a few.[5]
While several models exist to guide and direct primary care such as community-oriented primary care, expanded chronic care and the recently developed conceptual framework for analysis of the role of primary care, educators can provide a firmer base by considering two recommendations:
1. Ensuring APRNS become proficient in using various models aimed at changing health and health behaviors --individual models such as the health belief model; interpersonal level models such as the theory of reasoned action and community level models such as Bronfenbrenner’s bio- ecological systems theory. Ecological approaches, in particular, can help the future workforce better understand health from multiple levelsintrapersonal, interpersonal, institutional, community and public policy.[6]
2. Ensuring deliberate action on where and how APRNs are educated. [7,8] Educators must create innovative models that will provide students with learning experiences in patient-centered and population focused and even global environments spanning the care continuum.[9,10]
If advanced practice registered nurses are to take a leadership role in redesigning the health care system, they must have a better understanding about what keeps people healthy or leaves them vulnerable to becoming ill.[11] They must also develop a broad vision and understanding of health from a global perspective to use trending, forecasting, visioning, and political “know how” to help design the systems of the future in an increasingly complex world.[12].
