Click to Enlarge: Subjective self-reported time spent may not sum to 100% across activities due to overlapping responsibilities and multitasking. All comparisons of RNs and LPN/LVNs derived from Wilcoxon rank sum test, where P < .05. Source: JAMA Network Open
CHARLESTON, SC — In the VHA’s Patient Aligned Care Teams (PACTS) system to provide optimal primary care (PC) for veterans, all members of the PACT are expected to function at the top of their training and scope. That is not the case, however, with nurses, according to a recent survey and analysis.
“This study found that VHA PC nursing work generally aligned with that of the VHA PACT handbook, but nurses were not performing to their full scope of practice,” wrote the study team led by the VA Charleston, SC, Healthcare System. The Los Angeles VA Healthcare System and the VHA Office of Primary Care also helped conduct the research.
The research letter in JAMA Network Open explained that PACT staff includes administrative clerks, registered nurses (RNs), licensed practical or vocational nurses (LPN/LVNs) and PC practitioners, “Nurses perform diverse responsibilities broadly represented in the VHA PACT handbook,” according to the researchers, who added, “Primary care nursing work remains poorly quantified due to inadequate workload capture, as nursing work is usually subsumed under clinician encounters2; therefore, staffing models cannot be optimized.”1
The study was conducted by Chelsea McConnell, BSN, DNP-FNP, of the VA Charleston Health Care System, and colleagues. The survey, administered in March 2022, was sent to 10,083 primary-care nurses and asked about 56 activities and how much time nurses spent performing them. A total of 3,284 nurses responded. Nearly 60% of respondents had at least 6 years of nursing experience, and 56.7% of RNs had bachelor’s degrees.1
The responses illustrated the breadth of nurses’ work. Among RNs, 96.0% reported performing patient assessments by telephone, 94.4% making post-discharge contacts, 93.6% providing care coordination and 93.0% managing secure messages. RNs also reported counseling patients and families, managing chronic disease, identifying gaps in care, conducting in-person and video assessments and placing orders under protocols.
LPN/LVNs reported a different mix of responsibilities. They were more likely than RNs to perform immunizations, injections, electrocardiography and health screenings. For example, 97.0% of LPN/LVNs reported administering immunizations, compared with 88.5% of RNs. Depression screening was reported by 96.8% of LPN/LVNs and 82.6% of RNs.
Administrative work also accounted for a substantial share of nursing activities. Among RNs, 83.0% reported obtaining non-VA medical records, 85.1% faxing and managing medical records, 67.9% completing forms and 49.8% sorting incoming mail. LPN/LVNs also reported considerable involvement in administrative tasks.
The survey examined not only which activities nurses performed but also how they allocated their time. RNs reported spending the most time on care coordination, administrative work and triage or patient assessment, with much less time devoted to chronic disease and panel population management.
LPN/LVNs spent the most time on healthcare screening, followed by administrative work and very little time on panel population management. Both groups reported spending considerable time on healthcare education and counseling.
The results indicated that, compared with LPN/LVNs, RNs reported performing more:
- VHA and non-VHA care coordination (1,816 [93.6% vs. 798 [58.5%]),
- Administrative activities (e.g., obtaining medical records, 1,610 [83.0%] vs. 919 [67.4%]),
- Post-discharge contact (1,831 [94.4%] vs. 666 [48.9%]),
- Patient and family counseling (1,765 [91.0%] vs. 992 [72.8%]),
- Patient assessment (e.g., via phone, 1,862 [96.0%] vs. 730 [53.6%]),
- Panel population management to identify care gaps and perform previsit planning (1.461 [75.3%] vs. 659 [48.3%]),
- Placing orders per protocol (e.g., radiographs, 1,408 [72.6%] vs. 307 [22.5%];
- Medication refills, 1415 [72.9%] vs. 747 [54.8%]), and
- Opioid prescription drug monitoring (974 [50.2%] vs. 469 [34.4%]).
At the same time, LPN/LVNs reported performing more:
- Immunizations (1,321 [97.0%] vs. 1,717 [88.5%]) and injections (1,089 [79.9%] vs. 1,330 [68.6%]),
- Clinic procedures (e.g., electrocardiography, 1,205 [88.4%] vs. 1535 [79.1%]), and
- Healthcare screenings (e.g., depression, 1,319 [96.8%] vs. 1,603 [82.6%]) (all P < 0.001).
All nurses reported spending time on healthcare education and counseling.
“This quality improvement study found that VHA PACT RNs and LPN/LVNs share many responsibilities, though their activities vary by role,” according to the authors. “RNs are trained to perform activities requiring critical thinking, eg, care coordination, chronic disease and population management, and RN-led visits (walk-ins), but they generally reported not working to their full scope of practice. LPN/LVNs are trained to perform patient intake, screenings, vital signs, and clinic flow management, although cross coverage of other roles may occur with staffing constraints. Both RNs and LPN/LVNs reported activities that generally align with the PACT handbook but performed considerably more administrative activities and spent less time on chronic disease and panel population management.”
The researchers suggested that, among the issues influencing activity performance were variable PACT implementation, competing priorities, variable staffing and uneven activity delegation. “Nurse activity variation may arise from differences in state practice limitations, competencies, certifications, and role confusion,” they pointed out. “Time spent on administrative tasks may be due to understaffed teams, lack of coverage contingency planning by discipline, or knowledge gaps in expected responsibilities. Commonly, PC nurses were less likely to perform chronic disease management and panel population management.”
The study had several limitations. The researchers did not adjust for respondent bias or covariates, and the findings might have limited generalizability to settings outside the VHA. In addition, nurses might be performing activities that were not included in the survey.
The authors said that measuring nursing work is an important step toward determining how primary-care teams should be staffed and organized. “Quantifying nursing work is essential to optimize the composition and function of PC teams,” they concluded.
- McConnell C, Jimenez EE, Pope C, et al. Nursing Activities and Role Variation in Veterans Health Administration Primary Care. JAMA Netw Open. 2026;9(8):e2631739. doi:10.1001/jamanetworkopen.2026.31739
