Team Up! Team-based primary and community care in action

An Ask Us Anything episode! 

Producer Michael makes a rare appearance on the podcast where he brings your questions to Sarah and Morgan.

They discuss key topics such as nurse role in primary care health promotion, disease prevention, and care coordination, highlighting the impact of nurses on patient care quality. The episode revisits topics discussed in previous episodes to drive their point home further, such as the differences between LPNs and RNs, the benefits of team-based care, and effective strategies for integrating nurses into family practices. There is an emphasis on support systems for new nurses, and the hosts provide resources you can access in the show notes below.

Special Thanks
============
Throughout this season you’ll hear from several amazing nurses:
  • Angela Wignall is a Registered Nurse who has worked in perinatal health and public health. Since recording this episode Angela has been promoted to the CEO of the Nurses and Nurse Practitioners of BC from her position as Senior Executive Director. Angela is also a board member at the Canadian Nurses Association.
  • Diana Boateng is a Registered Nurse and is working on her dual master’s degree in nursing and health informatics. In her Masters, she is a co-op student working with the Innovation Support Unit. Her background is mostly in acute care but she has been interested in exploring what it means to be a nurse in primary care.
  • Hannah Roy works as a Registered Nurse in primary care and urgent primary care. She has certified practice in STI management and is completing her Masters degree to be a nurse practitioner.
  • Jamie Duteil is a Registered Nurse and the Health System Improvement Director at Health Quality BC. She has managed urgent primary care centres and acute care centres.
  • Kacey Wall is a Registered Nurse and a diabetes educator, she has worked in primary care networks and is a team member of the Innovation Support Unit.
  • Nikki Kafal is a Registered Nurse and has spent her career working in emergency and critical care settings. She is completing a dual master degree in nursing and health informatics and joins the Innovation Support Unit as a co-op student.

Links and Resources
=============
TeamUP! Season 7 Episode 3
Diving into the differences between Licensed Practical Nurses and Registered Nurses within primary care settings.
TeamUP! Season 7 Episode 4
Learning about the complexities of being an employer of a primary care nurse within smaller private clinics.
TeamUP! Season 7 Episode 12
How nurses can facilitate care coordination in primary care to support complex patients.
Family Practice Services Committee Resources
Provides new supports for integrating a nurse into family practice, including links to the Nurse in Practice program, along with webinars, events, and a link to the Nurse Compass
Practice Support Coaches
Tools provided by FPSC in collaboration with the Division of Family Practice to support physicians and teams to help identify gaps, reduce overlap and redundancies, and identify quality improvements within practice.

What is Team Up! Team-based primary and community care in action?

A podcast that brings together primary care providers, healthcare planners, patients, innovators and others to talk about the changes that are happening in primary care in British Columbia.

Sarah: You have questions
about nurses in primary care?

Did you send them to us?

Are we going to try to answer
them as best as we can today?

Morgan SM7b-MixPre: You bet we are.

Sarah, I know that we've been
waiting for this episode for a while.

Sarah: It's an Ask Us Anything episode.

I have been looking forward to
being able to answer real questions.

Morgan SM7b-MixPre: I think this is going
to be both interesting and fun to do.

Plus, for a special treat, we've
got Michael, our producer with us.

Michael has been working with us since
earlier this year and has, among other

things, been our episode producer
for the last two seasons of Team Up.

He's kindly agreed to jump
on a mic for this episode and

read the questions for us.

Sarah: Hello, Michael.

It's great to have you on this
side of the podcast, finally.

Why don't you introduce yourself?

Michael: Hello.

Happy to join in on the
podcast for an episode..

I joined the ISU in January this
year and have really enjoyed

being a part of the team.

I come from a background in science
journalism, and you may have even seen me

on television on the Discovery Channel.

So I do know a thing or two
about hosting some, Q& as.

Sarah: Oh, see, it is
like a game show episode

Morgan SM7b-MixPre: Michael, it's
great to have you here and I'm

looking forward to you hosting
us should we just dive right in?

You've got questions for us, right?

Michael: Oh, there are lots.

We have quite a few.

I've picked the ones that I thought would
be most interesting, both for our audience

and for you to answer in the podcast.

I merged some similar questions
and tweaked a few to make

sure they're more general.

I should have enough to keep you two
talking for at least one episode.

Are you comfortable?

Morgan SM7b-MixPre: Yeah, I think so.

Sarah: I'm ready.

Feels like a game show.

Michael: Alright, so let's begin.

Let's start with some questions about
what nurses can do in primary care teams.

I have a couple easy ones to toss up.

First, Will nurses in primary care
have the opportunity to participate in

or lead health promotion and disease
prevention initiatives within the

practice?

Sarah: Ding, ding, ding.

Yes, I can answer this question and I
can rarely answer clinical questions,

but I've seen this in team mapping.

Nurses can really help
with, both of these.

You know, the nurse will play a
key role in in this part of the

practice, especially in a smaller
team, doing things from immunizations

to education, to working on specific
health goals for wellness and exercise.

this is one thing I think
that can also be missed.

So, it's a really great thing to discuss
about how a nurse can intentionally

develop this in the practice,
so a real focus on, prevention.

Do you agree, Morgan?

Morgan SM7b-MixPre: I do.

I think it's definitely
in scope for nurses.

I think both for LPNs, Sarah,
and registered nurses, RNs.

and this should be part of
our practice and it's not.

always sort of top of mind.

So I think, as you said, it's, it's a
good point that this can sometimes be

missed and it's a great opportunity
for a nurse to bring this to the fore.

some ways you can do it, you can
have group visits, you can have

a group education visits or have
special clinics like an immunization

clinic that nurses can run.

I think this is a great way to sort of
promote nurses in your practice as well.

Michael: Alright.

Next question.

Will nurses in primary care be involved
in care coordination with other health

services?

Sarah: Yes, I think they should
definitely be involved in coordination,

both in the team and between services.

Morgan SM7b-MixPre: Yeah,
I agree here too, Sarah.

These, these are good questions.

go back to episode.

12 if you want.

I did a little team bit on
coordination and Sarah, I did that

while you were away in Thailand.

I think nurses, I mean, they're really
good at coordination and I think they

can complement what an MOA does in
a smaller team where the nurses can

coordinate the clinical aspects like
the transitions in and out of hospital

and leaving the MOAs to work on some
of the more administrative parts.

Michael: But are there specific
priority populations that

nurses in primary care will

focus on?

Morgan SM7b-MixPre:
Oh, that, that depends.

Sarah: I knew you'd say it depends
for at least one answer, Morgan.

Morgan SM7b-MixPre: Well, Sarah, it does.

I mean, it depends on so many things.

Like, you know, what
does the team want to do?

what's the practice and the population?

What are their needs?

you have a frail population, you
know, or if you have a young family

population with lots of kids,
the focus is going to change.

It'll depend.

Sarah: It's also a bit of a
collective decision, isn't it?

You need to talk about this as a team
to decide, where or if the nurse is

going to be focusing in different areas.

You can talk about it as
part of a hiring process.

And then again, as part of the working
together, you know, what's our purpose?

where do we really want to focus?

How do we want to work?

Morgan SM7b-MixPre: Sarah, Michael, if
I had to say yes or no, I'll say yes.

and it wouldn't only be
this specific population.

I would try to think about the
focus, in a way it sort of talk

about what is the practice needs.

what's the scope of a nurse?

And then what are the individual
interests and try to marry those pieces

together, thinking and then about,
you know, do you need to have any

special training to make that, that
focus work better and go from there?

Sarah: Same goes for the nurse
practitioner or family doctor then, right?

They can focus a bit
more as well in a team.

Morgan SM7b-MixPre: Yeah, again, Sarah,
I think within their scope of practice,

of course, but, as the team works
collectively together to figure out.

where everybody's interests are, then
you end up focusing, you know, as a

family doctor, I can focus a bit more
on the things that I like to do and

I'm skilled to do, whereas the nurse
can focus on other parts that they like

to do and that they're skilled to do.

Michael: So I guess the depends
does kind of make sense here.

Morgan SM7b-MixPre: Of course it does.

Michael: Well, how will nurses in primary
care contribute to improving patient care

quality and health outcomes specifically?

Sarah: Now, this kind of
relates to our last question,

Morgan SM7b-MixPre: Yeah.

And, I mean, of course I'm going
to say it's another, it depends

because you need to have some
specific discussions within the team.

And there are many ways nurses can support
that high quality primary care, from

planning and health promotion like we
started with to triaging sick patients.

Sarah: and I think, you
know, it's important to talk

about it to set some goals.

The teams that we've worked with that
have, you know, these really clear goals

are more likely to reach them, plan
some quality improvement activities,

test out different ways of, of doing
things to figure out how they're going

to change the way they're working
to meet whatever goals they set.

Morgan SM7b-MixPre: And if you're talking
about, care quality and outcomes, I

think you want to also think about
activity goals as well as outcome goals.

Sarah: Can you expand on
this idea of activity goals?

Morgan SM7b-MixPre: Oh, sure.

Sure, Sarah.

So an activity goal is something that you
might talk about tracking that you do.

so some people might call
it a leading indicator.

but things that you could easily
measure now that are happening.

then you'd expect those to lead into
those longer term outcome goals.

So I'll give you a clinical example.

activity goal might be how often
Do you check blood pressure or

how many people per week are
you checking blood pressures on?

An outcome then would be something
that's further down the path that It was

related to you checking blood pressure,
like how many people or what percentage

of people with high blood pressure
have now controlled blood pressure, and

then you expect that to take some time.

Sarah: Right, so that makes sense if
you monitor both, but can see changes

kind of in the activity sooner.

Did that answer the question, Michael?

Michael: Yeah, I think so.

That was, that was pretty good.

My next question for you though
is, how does the scope of practice

differ between RNs and LPNs in

primary care?

Sarah: Oh, again, this is
something I learned this season.

Ding, ding, ding.

Um, I know this one.

We actually have a whole
episode about this.

So episode three, is where we
really focused on, this idea.

The key takeaway for me was that LPNs
focus on patients with conditions

that are stable and predictable.

there's a lot of overlap in terms of
different kinds of conditions, but the

RN scope is a little broader and they
have more autonomy to exercise their

clinical judgment when patients are
less stable, like triaging new symptoms.

Morgan SM7b-MixPre: Yeah,
Sarah, totally agree.

And I think whenever we talk about
scope, always confirm with a college,

talk to NNPBC your provincial college
of nursing, because scope will change.

And so it's always good to double check.

Michael: here's a question more
around how the nurse impacts the PCP.

How does having a nurse change
the workload and responsibility

of the family physicians and nurse
practitioners in the practice?

Sarah: Oh, this is a good question.

Morgan, has anything changed for
you when working with a nurse?

Morgan SM7b-MixPre: Oh, gosh, Sarah.

Yeah.

I mean, lots has changed.

okay.

So in some ways, things
haven't changed too much.

My scope of practice and
stuff is still the same.

And I do usually see
patients one on one for care.

Then we get to collaborate and explore
care options when we're working together.

And that's something that's really hard
to do when you're not working together.

You know, I can get some extra help
with patients when I need it and I

can jump in and help a nurse when
they need some extra support as well.

And that back and forth makes for both
more effective care and efficient care.

And we were actually just talking
about this in a workshop just right

before this recording where, You
know, that efficiency piece can come

in if you think about how to work
a little bit differently together.

One thing I, I don't worry about so much,
and maybe this is a bit of a tangent, but

I don't, don't have to worry about hiring
and the sort of employer employee aspects

of having a nurse in practice because
I work at a community health center

where that's all handled separately.

And I think that's different for somebody
who's working in a primary care office.

So that'd be a bigger change to think
about too, as a primary care provider.

Sarah: And we talked about this as
well this season, so I think if people

are interested in that, we have an
episode on employer responsibilities.

Morgan SM7b-MixPre: So Sarah, what have
you seen perhaps like in team mapping

sessions that you've run where, or
other clinics that you've worked with

where they've been bringing in a nurse?

What's

changed?

Sarah: Some of the, most obvious changes
that I've seen have really been in those,

you know, we had this great example
of, practice that had been working with

a nurse almost in more of a referral
way with a community nurse who they

wanted to bring more into the team.

Anyways, at the time we were
doing this mapping was the first

time that the nurse had actually
met the provider face to face.

They'd been working together for a
long time, kind of over the phone.

And they had this wonderful
conversation about.

immunizations.

And she's like, Oh, I used
to work in public health.

I love doing immunizations.

I don't get to do that anymore.

And we had this moment of.

Really?

You love doing these?

Would you like to do more?

Like you, you could take that piece.

And, and they were both so excited
about this simple change in, practice.

you know, those kinds of conversations,
that's a very, very tangible

example of a clinical piece.

But then we also see that so many
opportunities where, nurses are often

coming into practice with a whole
breadth of experience from whatever

they were doing before that can
really add to educational resources.

I know we worked with one team where
One of the nurses previously worked

for a diabetes education center.

So all of a sudden, she became sort of
that key resource able to link and do

more in that space than the clinic had
originally, , anticipated and it's all

because they had these conversations
around who could look after this patient,

what are different resources, how might
we map out care differently to kind of

get those coordination pieces into place.

Morgan SM7b-MixPre: that's a
really good couple of examples.

And in our practice, we've had foot care
is another one where one of our nurses had

that as a special interest and suddenly we
were able to offer it within the clinic.

So our scope of practice for
the whole clinic changed when we

had that skill set in the team.

Michael: I'm going to
shift gears one other time.

We have a couple final questions
around onboarding and support,

and I'll ask them together, and
you have to answer both of them.

You can't just pick and
choose, gotta be both.

So firstly, what kind of training
or orientation will be provided to

nurses joining a family practice?

And What kind of support or resources
will be available to nurses through

the BC Nurse in Practice program?

Sarah: So this is kind of very BC
specific answer, but there's some

generalizable pieces in here, I think,
and let's tackle these in order.

I think practices really should
plan for an orientation process

and an onboarding process.

And this isn't just for nurses.

This is really for, for any role
coming into a team, , that includes.

The, physician, , all of these people have
to be on boarded and on boarded together.

Um, understanding nursing scope
practice too is to be something that's,

you know, spread across the team.

So not just a quick pop in,
this is a new person, they're

going to be joining next week.

but you know, an actual structured
onboarding process that gives

people time to learn about
each other and, how they work.

Morgan SM7b-MixPre: And so I think
that learning about each other

is important in both, directions.

Because you're a physician and you haven't
worked with a nurse in primary care,

you don't know the scope and you might
make some bold assumptions that really

limit what a nurse can do in practice.

And that's, that's important.

That's not a great way to start, and
it can take a while to move past that.

So taking that time at the beginning
to understand somebody's scope

of practice is really important.

we talked about this a bunch in
the season, and I think there's

several things that practice can do.

it's learning the benefits of nurses in
practice, not just I want to have one

because everyone else hiring nurses.

But what's the benefit for our practice?

There's that figuring out that, that
whole employer relationship and what

are those requirements and that's all
pre work and then thinking about why

in your practice a nurse is joining
and what are some of those goals that

came out in that earlier question,
Michael, about outcomes and goals.

Then there's also beyond the
onboarding for the nurse, there's

the onboarding for the practice, the
patients, let them know that the nurse

is coming and what does that mean?

Sarah: and this is so important.

We, we heard this in our
patient centered work.

often this isn't being communicated to
people that, you know, there's new people

joining a practice or that things might
shift or that there's new resources.

It's a great positive benefit for
patients if they know about it.

Morgan SM7b-MixPre: Yeah, so all those
things, and then the orientation,

as you mentioned, to get specific,
and this is fairly general.

I love the shared visits as a way
to get to work together and as a

way for patients to get to know
the nurse as the nurse has more So,

Capacity first in the first couple of
weeks before they start to get busy.

It's a great way to
help onboard and orient.

Sarah: And this is all practice
dependent though, right?

Morgan SM7b-MixPre: Yeah.

There's not, really a, at least in BC,
there's not really a big onboarding

manual that I'm aware of yet.

And I think some stuff might be coming
along, but it's not there at the moment.

so if you're hiring a new team member
into your practice, you know, think

about what you want to do for that
within the practice and then plan that.

so there's a lot, to sort of wrap
around in those first couple of weeks.

Sarah: At the program level, now the
second question was really around,

you know, what supports are available.

there are supports for
Practices and nurses.

And this again is going
to be really BC specific.

In other provinces.

I think there's similar kinds
of overall supports, but they

have different names and stuff.

So in BC, it's the BC Family
Practice Services Committee has a

new set of provincial supports and
webinars, for practices that are

bringing in a nurse in practice.

That's really going to help with the
piece of You know, orienting a nurse to

practice and getting everybody kind of
on the team on the same page and the BC

practice support coaches are also there as
a great resource to help practices figure

out how to work together better as a team.

We definitely think that getting a
coach in to help with these things.

Things like team agreements, team mapping,
to get you working together helps.

We've just seen so much value there.

And then in BC, nurses are also going to
be able to access NNPBC's resources and

their program is currently being designed,
kind of an education and support program

for nurses in practice in primary care,

Morgan SM7b-MixPre: And I think
getting support as a nurse from

other nurses is really important.

And it's hard to do that if you're a
solo nurse in a practice, which I think

a lot of our nurses that are being
hired right now in BC are going to be

solo nurses in a practice of, a few
physicians and nurse practitioners.

now in our practice at Kool Aid,
we have over a dozen nurses.

Sarah: including a new
honorary nurse, right?

I think I just heard that
there's a new one on your team.

Morgan SM7b-MixPre: Yeah.

Well, yeah, there is.

but even if you don't include
the honorary nurse, we still have

more than a dozen real nurses,
that actively support each other.

and if I can digress a little bit, for
this, I was working on the van just

yesterday and I got to work with our
newest, addition to the nursing team.

Oliver did Great job.

And I really enjoy working with him.

so just a little shout out to Oliver.

It's great to have you at Kool
Aid, and yesterday we had some

really complex patients on the van.

and I want a place to show up for some
complex care, but we had one person who

was post hospital post surgical with
complex non healing wound issues on a van.

Perfect, right?

But it was great to see how Oliver was
supported by the rest of the nursing team.

He was able to reach out, get some
phone calls, brainstorm not only what

to do in the moment, but then to make
sure we had, proper follow up care back

at the clinic within a couple of days.

So it was really neat to see how
a nursing team supports, a new

nurse in the, in our practice.

Sarah: And Morgan, like you said,
if you're in a small practice,

you're not going to have all of
that additional support built in.

So you need to find kind of
mentorship outside of the practice.

I think that's really where NNPBC is
creating the nurse support program.

we'll put links into the show notes
on how you can access that in BC.

Morgan SM7b-MixPre: completely agree, and
the nurse is joining a smaller practice,

you have to make sure you find that either
formal or informal supports that network

around you of other primary care nurses.

Michael: Alright, Sarah and Morgan,
I think those are all the questions

I have for you in this episode.

Well done, you did very well.

And I learned quite a few things.

and I will say, I wasn't keeping score,
but I think if I was, Sarah would have

won.

Morgan SM7b-MixPre: She was

Sarah: What did I win?

What did I win?

Michael: She was fast.

Morgan SM7b-MixPre:
Well, Michael, thank you.

It's been great to have you on the episode
with us, not just behind the scenes.

So yeah, it was great to have you here.

Sarah: And we really like these kinds of
episodes in case you didn't pick that up.

So if you do have any questions
or topic suggestions, please

email us at isu at familymed.

ubc.

ca.

Morgan SM7b-MixPre: Yes.

We definitely like this and,
and getting the, the input

and the feedback is fantastic.

So thanks for listening.

Sarah: See you next time on Team Up.

The Innovation Support Unit is a
distributed multidisciplinary team.

We work mostly remotely from communities
across the Lower Mainland and

Vancouver Island in British Columbia.

Morgan: Sarah and I are both recording
from our offices in the territories

of the Lekwungen speaking peoples, the
Songhees and Esquimalt First Nations.

Sarah: And recognizing the colonial
history and the ongoing impacts of

colonization and healthcare systems
and in Indigenous communities in

Canada and around the world, as we
move through the season, we'll work

to bring an equity lens to this work.

And we really encourage you, our
listener, to reflect on your past,

present, and future participation.

On the indigenous lands
where you are situated.

Morgan: we'll see you in
the next episode of team up.