The Professional Practice of Registered Nurses

[Letter]. Perm J 2014 Spring; 18(2):95 [Full Citation]

Re: Rondinelli JL, Omery AK, Crawford CL, Johnson JA. Self-reported activities and outcomes of ambulatory care staff registered nurses: an exploration. Perm J 2014 Winter;18(1);e108-15.

Dear Editor,

Rondinelli et al offer much-needed insight into the professional practice of registered nurses in ambulatory care.1 Clearly nurses are taking part in complex patient care activities and are having a positive effect on patient outcomes in a variety of ways. However, one finding in the survey gives some cause for concern. Sixteen percent of staff nurses had a master's degree or higher. Yet many of the nurses spend much of their time on assessment activities and thus might not be being used to their maximum capacity.

This has implications for the effectiveness of nurses and also for their cost effectiveness. It is commonly stated that nurse provision of care is more cost effective than physician provision of care, but this may not be true in all circumstances. For it to be true, nurses must be delivering the same quantity and quality of care at a lower cost or a higher quantity or quality of care at the same cost. The cost of nurse education is a factor in this equation. Nurse education is typically of shorter duration and thus of lower cost than physician education, but if nurses are educated to masters level, their education may be neither shorter nor less expensive. Thus, cost effectiveness of health care professional education must be considered as an aspect of the cost effectiveness of care.2

This is not straightforward because the cost of health care professional education and the cost of care are notoriously difficult to measure. However, the potential reward is great also: a cohort of nurses who deliver high-quality, low-cost care and whose education is less expensive.

Yours Sincerely,

Kieran Walsh, MD, FRCPI

Clinical Director of BMJ Learning

BMJ Learning, London, UK

   1.  Rondinelli JL, Omery AK, Crawford CL, Johnson JA. Self-reported activities and outcomes of ambulatory care staff registered nurses: an exploration. Perm J 2014 Winter;18(1):e108-15. DOI:
   2.  Walsh K, Levin H, Jaye P, Gazzard J. Cost analyses approaches in medical education: there are no simple solutions. Med Educ 2013 Oct;47(10):962-8. DOI:

Response to Dr Walsh

Thank you for the opportunity to respond to Dr Walsh's thoughtful letter to the editor. As authors of this exploratory study, we realize questions will arise from the evidence on the ambulatory nurses' role in the 21st century. Although cost effectiveness was not part of our study, we agree with Dr Walsh that cost effectiveness is a consideration when providing quality health care. We encourage the start of conversations, potential improvement projects, and future research related to our findings. We envision that ambulatory staff registered nurse roles are complimentary to physician or clinician provision of care, with each professional practicing to their own scope of practice to deliver team-based, high-quality, and effective patient care.

Yours sincerely and on behalf of the coauthors,

June L Rondinelli, PhD(c), RN, CNS

Kaiser Permanente, Southern California

Regional Patient Care Services, Regional Nursing Research Program







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