nurse writing on tablet with stethoscope around neck
Heidi Mennenga

Heidi Mennenga, PhD, RN, CNE, UNLV School of Nursing alumna and Interim Associate Dean for Academic Programs/Associate Professor, South Dakota State University College of Nursing

Oct. 22, 2021

By Joseph Gaccione (UNLV School of Nursing Associate Director of Communications)

UNLV Nursing alumna Heidi Mennenga is on a mission to help shake up the primary care model of treatment. She wants to add more registered nurses in primary care.

Mennenga is currently the interim associate dean for academic programs at South Dakota State University. Previously, she graduated from UNLV Nursing with her Ph.D. in 2010, with her dissertation work focused on team-based learning.  In many ways, her doctoral research helped prepare her for advocating for more RNs in primary care settings, a campaign that promotes teamwork, nurse empowerment, and above all, a greater chance to effectively treat patients.

Benefits and Obstacles

Mennenga is project director on a $2.7 million HRSA grant that funds research and training based on promoting more registered nurses in the primary care setting.  She says registered nurses could maximize the scope of their licensure in an area mostly dominated by medical assistants.  “If it's a specialty clinic, a lot of times they'll employ RNs,” she says, “but in your primary care family practice type setting, seldomly are they going to have RNs present.” Mennenga credits the Josiah Jr. Macy Foundation for spearheading a bigger conversation on this topic, which not only gives RNs more opportunities but frees up primary care provider workloads.  “The Macy Foundation acknowledges we have a shortage of family practice providers and these providers can't handle the influx of patients we're seeing because of the affordable care act," Mennenga explains. "How could we alleviate their workload and utilize other members of the healthcare team better so it lessens them up? Using other members of the healthcare team to their full scope frees the providers up a little bit and allows us to provide team-based care in the primary care setting.”

Mennenga says primary care teams take responsibility for patients together, but often times, patients are treated for immediate ailments but other issues are ignored or fall through the cracks. She says, “If you had a team-based delivery of care model, as well as having an RN who is saying, ‘Wait a minute, we need to holistically treat this patient, you could provide better patient care, but it also isn't all falling onto that primary care provider.” She adds RNs can do a myriad of tasks based on standing orders, from chronic disease management; acute illness management; medication adjustment; and patient education.  But having more RNs in primary care is challenging for several reasons.  The first issue is with the clinics themselves. Mennenga acknowledges it is difficult to convince clinics to pay more money for RNs (compared to an LPN or medical assistant).  “It's making them see in the immediate time it's costing you more, but later down the road, you're going to have better patient outcomes,” she contends. “You're going to save money in the long run because your patients are going to have better outcomes.” She also says while some clinics embrace the idea of having RNs who are practicing to the full scope of their license, others either prefer to utilize LPNs or medical assistants or they utilize RNs who are doing tasks that could be done by an LPN or medical assistant.   

Additionally, role shifts would occur, not only to fit RNs into the team but also clarify what it is each team member does to avoid confusion. Mennenga says, “We shouldn't have RNs doing what the LPN can do because that's their role. We should be using LPN to room patients, take their vital signs and get their history. It makes sense to use the RN to the full scope of their license and do things the LPN can't do, so there really is a place for everybody.” She adds providers would have to agree to let go of some responsibilities they normally do by allowing a registered nurse to do them.  The third challenge is what Mennenga calls the biggest barrier – lack of insurance reimbursement.  She says because Medicare and Medicaid do not currently reimburse clinics for most RN only-type visits, it would dissuade these facilities from employing more RNs. “Obviously if a clinic isn't going to get reimbursement because the patient didn't see a provider and they can't code for it, they can't bill for it," Mennenga says. "They're not getting paid, they're not going to do it. Changes need to occur at the state and federal level to allow for reimbursement and embrace what registered nurses can do in the primary care setting. ”

Academic Adapations

At South Dakota State University, Mennenga and her team used their HRSA funds to develop curriculum for their undergraduate students to learn about nurses in primary care settings and to see them practicing with the full scope of their license. In addition to didactic curriculum that all students receive, interested students in their fourth and final semesters go into primary care with a preceptor to see first-hand what it’s like for both nurses and the entire interdisciplinary team keeping patients healthy and out of the hospital. A detailed evaluation plan, which is part of the grant requirements, helps Mennenga and her team evaluate the project outcomes.

So far, Mennenga says students enjoy the primary case-based clinical. Not only do they see another environment to work in besides a hospital, but they are absorbing higher level nursing issues. She says, “They'll talk about things such as healthcare quality, healthcare equity, and being an advocate for the patient in that primary care setting. They'll talk about continuity of healthcare. They'll talk about billing and reimbursement issues. They don’t always talk about these types of concepts with their typical acute care clinical rotations.”  She also says these primary care environments show the students there is more they can do with their license that they don’t see on a day-to-day basis. On a larger scale, Mennenga lauds the grant for allowing them to tap into educational research they wouldn’t have had without these extra funds.  “We're collecting a lot of data, which is program evaluation-type data, but it has already produced several manuscripts and presentations," she says. "We had a book chapter just recently published in a rural nursing book. We've had great dissemination opportunities from the grant.”

A Team-Based Background

When it comes to learning about what’s best for a team, Mennenga draws on her own research.  Her dissertation at UNLV focused on team-based learning for nursing, which she labeled a relatively new methodology during her time in school, especially in nursing. “It was not being used at my home university, and I was intrigued by it,” she says. “I watched a couple of faculty members at UNLV who were using it and felt like it was a truly evidence-based teaching strategy that needed to be more widely used and researched in nursing education.”

Team-based learning is a structured teaching strategy.  Students work in teams throughout the semester on applying content learned as opposed to sitting through lectures the entire time.  The students would still do the work, but they’d prepare beforehand. Mennenga said at the time, nurse educators were hesitant to embrace this modality of teaching.  “It was a newer concept to think our students would do this prep work outside of class and not have to listen to us lecture, that they would come to class and actually apply the content.” She adds team-based learning adds a level of accountability for both the student and their team to prepare for class.  “It's one thing if I come and take a quiz and I perform poorly for myself, but if I'm taking a quiz with my team and it’s clear I didn’t prepare, I'm going to be a little embarrassed that somebody else knows that,” she explains.  “There's that level of peer pressure to prepare for class so that they're able to work together as a team.” But that pressure is worth it, Mennenga argues. “One of the things I heard when I started using it was, ‘I hate to work in teams,’” she recalls.  “Now I start my classes where I'm using team-based learning by saying, ‘If you don't like to work in teams, you're in the wrong profession because you're going to work in a team unless you are a home health provider in a very rural setting, [where] your team interaction might be a little more limited.’”

Forward Thinking

Currently, Mennenga’s project has funding through June 2022 with plans to continue the RN in primary care curriculum. She admits there are still academic obstacles to overcome, in addition to the systemic challenges of RNs in primary care.  Though the didactic portion of these primary care courses are sustainable, she says she and her team have to figure out how to pare down the clinical hours while making sure their community partners can handle large amounts of students.  But Mennenga is confident in sustaining the programs as provider shortages exist, especially in more rural areas. “I think we're going to see that demand eventually get to a point where the clinics don't have an option to say no to having an RN," she predicts. "They'll recognize they really do need to have one that's capable of practicing to the full scope of their license.”

Mennenga says her passion for having more RNs in primary care keeps her committed to this cause. She says her enthusiasm is two-fold.  One part is emphasizing how important it is to teach students that RNs in primary care may be a future career opportunity for them; otherwise, they may not be aware of it.  The other part of Mennenga’s passion for RNs in primary care is from a human perspective. “We're all patients at one point in time, and our loved ones are all patients at one point in time,” she says. “Knowing that it could improve patient outcomes and patient delivery certainly is a motivating point.”

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