Family practice registered nurses

Trusting relationships

Our findings revealed that building strong nurse-patient relationships was critical to the role of the FP-RN. The depth of nurse-patient relationships allowed FP-RNs to obtain information that might not otherwise be disclosed. For instance, one physician said, “There are now things that the younger crowd will relay to [the nurse] in a sexual history that they don’t tell me.” Many of the FP-RNs acknowledged that in the family practice setting, established trust with patients intensified over time. They seemed to think that trust and relationships with patients were more easily developed within family practices that valued continuity of care. One nurse noted that “family practice nurses get to see the impact of their decisions, and the impact of their advice” over time. In acute care settings, “a nurse will make decisions, but once that patient’s out, that’s it.”

We found that nurse participants had an important effect on patient care through the support they provided and the health education they imparted. One family physician described a successful intervention influenced by the clinical relationship between an FP-RN and an obese patient who had diabetes. He concluded his account by noting: “It’s a wonderful story in terms of the bond, the trust, the relationship that exists with the nurse.”

The importance of trust also emerged from narratives describing relationships between FP-RNs and their health professional colleagues. Trust was more easily garnered by the FP-RNs when they were able to demonstrate their clinical acumen. As one family physician said of the nurse he worked with: “I value her judgments with regard to patient care. If she thinks someone needs to be seen, and when, and how, I value that, I follow her advice, and if she disagrees with me then she’ll say so.”

Another physician described the FP-RN in their clinic as “ha[ving] an authority we can really trust.”

Balancing multiple priorities in the provision of coordinated care

Exemplary FP-RNs were able to balance multiple priorities, including the simultaneous, unpredictable, and immediate needs of many patients and colleagues. Compared with the hospital setting, one participant explained, “It’s a real skill in family practice nursing, identifying those red flags of who needs to be seen—that triaging function.” The ability to quickly assess and prioritize those patients who needed to be seen sooner set exemplary FP-RNs apart. Oftentimes the FP-RNs’ triaging competence, coupled with an expert knowledge of the patient population, resulted in better and quicker care. Being attuned to individuals and knowing when critical situations needed to be addressed was deeply important. We heard such stories about a nurse who recognized a patient was in acute heart failure by just seeing the patient in the waiting room; a nurse who convinced a stoic patient on the telephone to seek medical attention based on her conversation; and a nurse who knew that simply sitting and listening to a crying patient would provide the type of care needed. The seemingly intuitive sense of knowing the patient and knowing how to prioritize needs was an attribute seen across all the FP-RNs studied.

It became evident that FP-RNs were also skilled in prioritizing the needs of the clinic’s operational flow. One nurse stated: “I usually come in early because I need to know I’ve got my things in order before the patients start coming.” Another explained of her organizational methodologies, “I know right in the beginning who is going to be coming in, which doctors are working, and I get their stuff ready to make sure I’m ready for them.” Exemplary FP-RNs were able to proactively deal with the unexpected. One physician described that if the nurse saw that the fridge was broken, “she [would] call public health and find out which vaccines we [could] use and which [were] kaput; I wouldn’t have the foggiest [idea] and I just trust her to call public health and figure it out.” Another counted on her nurse partner to manage the clinic flow: “[S]he will knock on my door if I’m taking too long, like with a physical exam. She keeps me on task.” The awareness of the clinic system’s needs, health professionals’ needs, and patient care needs were skillfully balanced and prioritized.

Committed to learning the discipline of family practice nursing

The FP-RNs in this study were characterized as independent, motivated health care professionals, continuously refining and expanding their knowledge and skills. One participant explained that, for example, “clinical guidelines for things like immunization had been around for years but were not a focus in what I had to do [previously], so I needed upgrading.”

Given the absence of formal family practice registered nursing programs, the FP-RNs’ capacity for creating self-directed learning opportunities was critical to the optimization of their role. Many began their careers in acute care hospital settings, and entry to family practice came with a steep learning curve. The nurses created their own learning opportunities to optimize their family practice nursing roles, including volunteering at family planning clinics to gain experience or shadowing colleagues. We found an openness and flexibility toward lifelong learning, as they noted that “nothing stays the same” in family practice.

Many of the FP-RNs studied were able to skillfully, effectively, and purposefully gather information, knowing when and how to “stop and listen to people.” This specific skill enabled the FP-RN to go beyond simply “listen[ing] to the words” of the patient to “really hear[ing] what [was] being said.” As a result of the dialogues developed, FP-RNs demonstrated an ability to know their patients in a holistic manner, taking into account complex medical, social, and emotional needs. As another nurse reflected that the shift to family practice made “a big difference in the way you [as the nurse] look at a family as a whole.” The FP-RNs in our study successfully adapted and independently fulfilled the need to broaden their knowledge and skill as they developed their communication practices with their patients.

Recognizing family practice nursing as distinct

The nurses in this study distinguished between the type of care delivered in primary care and that delivered in acute care settings. One participant described nursing in acute care as regimented, “always [addressing] orders—give them this give them that.” Another explained, [The family practice setting] wasn’t like in the hospital where you did things to people. It was more like these are the people, what do they want? You have to give them what they want, not what you want to give them.

The FP-RNs thus played an important role in gathering information from the patients to develop a holistic understanding, which included lifestyle, familial, and socioeconomic circumstances. As illustrated by one nurse’s story, the ability to effectively gather, process, and act on patient information over the long-term is an acquired skill unique to the FP-RN and different from the acute setting: When I first started in [family practice] people would show up and would be having nervous breakdowns, and I didn’t know what to do with that .... [S]uddenly, there are patients that are telling you their problems, and I had no clue what was wrong with them .... [I]t took me probably at least 2 or 3 years before I was able to look at things in a pattern recognition kind of way .... [W]hen I think about it now, I probably wasn’t the best in terms of being empathetic or understanding what the family dynamic was. ’Cause all I had cared about previously was the patient in the bed.

One FP-RN highlighted the notion of the uniqueness of “family” in “family practice”: You’re in an environment where this person in front of you is sick, but that person is the dad and now he can’t go to work. And because he can’t go to work the kids won’t get new snow boots. So [the shift to family practice] makes a big difference in the way you [as the nurse] look at a family as a whole.