The Role of Nurses in Primary Care Reform: “The Wheel and Hub of Health Care System

Nina Mamishi, RN, BScN, MScN,MSc(c)1
Published online: 03 November 2017
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1Department of Family Medicine, McGill University, Montréal, Canada.

The McGill Primary Healthcare Symposium in 2016 highlighted the interdisciplinary accord on the challenges that the Québec primary healthcare system has chronically been facing. It was accentuated that all proposed reform models lacked a focus on the role of nurses, reflecting the solitary medical team dominance. Doctors are appreciated as central players in primary care, yet the multidisciplinary aspect of the healthcare system needs to be more carefully considered. Unfortunately, the nursing role in our debilitated healthcare system has been profoundly undermined. Indeed, in many successful reform models, nurses have represented the backbone as well as a quick-fix to many system cracks (2).

Nurses are the largest group of healthcare professionals in Canada (3). According to the International Council of Nurses, “Nursing encompasses autonomous and collaborative care for individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and care for the ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.” (4)

Three stages of preventive care are all applied in the scope of nursing. The first is primary prevention, which involves developing strategies to prevent risk factors and unhealthy behaviors, and might include educational programs on a group level, for children or youth, community or school. The second level is identifying currently sick people through conducting various screening programs, as well as regular checkups, in order to prevent the actual onset of disease by controlling risk factors. The third stage involves rehabilitation and management of an illness that has already occurred. All the stages of preventive care are focused on education, and nurses play a direct and fundamental role in managing preventive measures they practice uniquely for the patient-centered approach, which is a hallmark of preventive care (5,6). Nurses are in an ideal position to pursue the mission of education due to their close relationship with patients. Therefore, nurses are needed to help patients maintain their health and it is more important than treatment of the diseases due to the high cost of healthcare services.

Four types of chronic disease – cardiovascular disease, cancers, chronic obstructive pulmonary disease, and diabetes – account for nearly three-quarters of all deaths. Based on estimated percentages, the medical care costs for people with chronic diseases account for $39 billion a year in Canada. Because cancer and heart disease kill so many at an early age, the indirect costs of chronic illness due to productivity losses are particularly high, accounting for a total of $54.4 billion annually in indirect costs (7). As a result, the preventive role of a nurse should be highly valued and deserves increased recognition. (8)

Another essential role of nurses in the healthcare system is working as a research nurse. Nursing research has a tremendous influence on current and future professional nursing practice, thus rendering it an essential component of the education process. “Clinical research nursing combines the more familiar nursing responsibilities of holistic patient care with the world of clinical research protocols, governance and management” (9). The research nurse is actively involved in all phases of research. In the first phase of a research project, which is the development of a study protocol including clinical data collections and visits, research nurses have a substantial role as trained members of the team performing the clinical tests. Owing to the high level of trust and communication skills of nurses and close relationship between nurse and patient, obtaining informed consent is another responsibility of research nurses. Among the many other important responsibilities are patient recruitment, data collection, tissue and sample collection and processing.

Clinical research nurses often work on therapy-related studies (clinical trials). Being a clinical research nurse addresses the desire for knowledge and personal development due to the intellectually demanding nature of this work. Performing laboratory experiments, utilizing such analytical skills as qualitative and quantitative data interpretation, are additional competencies of a clinical research nurse. The role of the research nurse is diverse, rewarding and challenging. This responsibility calls for assertiveness, commitment, and high standards of clinical research. The results of nursing research are published in more than 100 credible journals each year (10,11).

As stated by the Canadian Nurses Association, nursing leadership, as other nursing roles, is linked with positivity of the patient, provider, and organizational outcomes. Nursing leadership plays an essential role in the immediate lives of nurses and has an impact on the entire health system. Canada’s health system needs creative and energetic nursing leaders throughout the discipline to support a modern, innovative and professional practice. The development of nursing leaders must begin at the level of education and continue throughout the career of every nurse. Leadership in this context is about helping nurses to accomplish their task. Moreover, to support high-quality professional practice and help nurses feel safe, respected and valued, there is an ethical obligation, in the case of a resource shortage, to adjust priorities which can be more easily accomplished with improved leadership. Leadership encompasses mentoring, coaching, supporting, rewarding and attracting other leaders at all levels. Nurse leaders must work collaboratively with healthcare professionals and policy-makers to build an improved future for the Canadian health system (12).

Nurse educators utilize a combination of clinical expertise and passion for teaching through working in the classroom, as well as in the practical setting, to prepare and mentor current and future generations of nurses. Nurse educators play a pivotal role in strengthening the nursing workforce. Formal academic programs are designed, implemented, evaluated and revised by nurse educators. They are responsible for assuring quality educational experiences that prepare the nursing workforce for a diverse healthcare environment by documenting the outcomes of educational programs. Being a nurse educator requires having strong communication skills, a solid clinical background, excellent critical thinking skills, knowledge and implementation of the theories of teaching, learning and curricula design. Leadership, innovation, and creativity are some other requirements.

The nursing profession and healthcare system needs registered nurses with advanced training to operate as leaders, researchers, educators, or advanced practice and nursing specialists. Indeed, more education may add up to big career advantages and advanced clinical skills are in high demand. In the age of managed care, disease prevention and cost-efficiency, there is a growing demand for nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. A doctoral degree allows a nurse to contribute to academia or to the clinic as a researcher in a healthcare setting. Becoming a leader in clinical research is often enhanced by a post-doctoral experience. In addition, in all these areas a nurse can be a mentor.

Positive comments about nurses have been publically and ubiquitously vocalized, yet I argue that such comments have not been fully realized. Moreover, the symbol of a nurse as an “angel” has been unhelpful, failing to convey the professional level of nurses. Nurses are highly educated, experienced and their profession encompasses a wide variety of valued elements that could be applied in the best way.

Satisfied nurses may improve hospital outcomes and consequently mortality. Today, every healthcare organization is invested in achieving and maintaining the best possible patient satisfaction scores. Among other benefits, patients are more likely to return if they have a positive experience (13). One of the best ways to improve patients’ experience at the facility is to make sure that the employees are engaged and satisfied with their work experience. Patients really do notice problems, and they may not always understand the technical details of what is happening during their care, but they notice the environment around them, including any sense of dissatisfaction or disrespect among the staff. That is why employee engagement is so crucial. Employees want to feel that their opinions matter, that their input is valued and that leadership is listening to them (14). Moreover, feeling chronically unappreciated can lead to burnout; a state of physical, mental, and emotional exhaustion characterized by feeling extremely overextended and depleted of one’s emotional and physical resources in response to chronic job stressors (15,16). Over the past three decades, job burnout has been studied by several researchers and they have all agreed that negative attitudes toward clients, reduced job performance, reduced organizational commitment, and depression are all its consequences (17).

It has been acknowledged that, for any given health team, physicians are the managers within the Canadian healthcare system. Nevertheless, I invite physicians to inspire the collaboration of all team members, including our valuable nurses, in order to share in the system’s sustainability.

As a matter of fact, in order to attain a higher patient safety index, neither profession can stand alone, therefore good collaboration is essential. Maximizing nurse-physician collaboration holds promise for improving patient care and creating satisfying work conditions – all key factors to successful primary care reform.

Nurses and the roles they play have been identified as elemental and crucial in the development, implementation and the sustainability of healthcare systems and healthcare reforms. Many healthcare systems have attributed their success and sustainability to the strong nursing role they have enjoyed. In contrast, disordered healthcare systems have chronically been implicated in the systematic underestimation of their nurses' roles (18). The Quebec healthcare system has entered, yet not departed, a chronic reform phase. I strongly attribute such chronicity to many causes, of which the persistently marginalized and under-looked nursing role may be one. The Quebec healthcare system, with its valuable universality, is facing a life-or-death battle that it can win. I envision the interdisciplinary collaboration in such a battle as essential and vital. Such collaboration must fairly and equally appreciate all members' roles.

“There are some of the barriers to change, and only by acknowledging and better understanding it will be possible to reduce their impact so we can move forward with the implementation of the solution needed to improve our system” (David Levine).



  1. Vahey D, Nurse Burnout and Patient Satisfaction. Med Care. 2004; 42(2):1157-1166. Available from:
  2. Committee document: Standing Committee on the Legislative Assembly- 2016.Bill 41, Patients First Act. Available from:
  3. Canadian Institute for Health Information. Regulated Nurses, 2014. Ottawa, ON: CIHI; 2015.
  4. Bartz CC. International Council of Nurses and person-centered care. International Journal of Integrated Care. 2010;10(5). DOI:
  5. Levine D. Healthcare and Politics: An Insider’s View on Managing and Sustaining HealthCare in Canada. First Edition. CA; Vehicule Press; 2015:276-281
  6. The Role of Nursing in Preventive Care, Nurse Together.Com. 2012.
  7. Mirolla M. 2004.The cost of chronic disease in Canada. The Chronic Disease Prevention Alliance of Canada
  8. Hussung T. How Nurses Play a Role in Preventive Care, NOTREDAME College online, [cited 2014 June 13]
  9. Canada Nurses association [Internet]. Effectiveness of Registered Nurses and Nurse Practitioners in Supporting Chronic Disease Self- Management: A Public Health Agency of Canada Funded Project; 2012. Available from:
  10. Gibbs CL, Lowton K. The role of the clinical research nurse. Nursing Standard. Date of acceptance: (2012). [Cited December 19 2011]; 26, 27, 37-40.
  11. Pick A et al. The Role of the Research Nurse. Nursing Practice Innovation Research. Nursing Times. 2011: [Cited 26.4.11]; 107: 1-2
  12. Gleason K. What is a research nurse and what do they do? Clinifield. 2013
  13. Maureen F.2004.Measuring nurse job satisfaction. Journal of Nursing Administration.34(6):283-290
  14. Canadian Nurses Association [CNA]. 2008: p. 9
  15. Larson J. The Connection Between Employee Satisfaction and Patient Satisfaction contributor, [Cited 2012 February 2]; Available from:
  16. Maslach C, Schaufeli W, Leiter M. Job burnout. Annul Rev Psychol. 2001;52(1):397–422.
  17. Kalliath T, Morris R. 2002. Job satisfaction among nurses: a predictor of burnout levels. JONA (Journal of Nursing Administration).32(12):648-654
  18. Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of hospital care environment on patient mortality and nurse outcomes. J Nurs Adm. 2008;38(5):223–229