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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: Are you interested in the
BC Nurse in Practice program?
Do you want to know more about how
this supports team based primary care?
Do you want to learn more about nurses
and the value they bring to patients?
Me too.
Oh, Morgan, I really liked doing
those intro questions, and when you
pitched this season, you wanted to
start with kind of the big picture.
What makes nurses and doctors different?
Morgan: Yeah, Sarah, I kind of know
what makes doctors and nurses different,
but I wanted to find out how to
better describe what I think I know.
So I asked several nurses to help me.
Sarah: And I really want to hear
about what you learned, because I'm
starting from kind of ground zero here.
what did you learn about
nursing as a profession?
Morgan: So I was reminded first off that
we're similar and yet we're different.
our goals I think are very similar, but
the way we approach patient centered
care is from our own disciplines.
And sometimes we can forget that if all
we do is we think of the tasks that we do.
If we think about what tasks nurses do in
primary care, instead of thinking about
more primary care nursing as a whole,
I think that gets missed sometimes.
so I got to spend some time talking
about nursing as a profession with one
of the experts in BC, Angela Wignall.
Angela is an RN who's worked in
perinatal health and public health.
She's the Senior Executive Director
for Nursing Programs and Policy at the
Nurses and Nurse Practitioners of British
Columbia, and she's a board member
at the Canadian Nurses Association.
Angela describes nurses in this way..
Angela: nurses engage in nursing.
We intersect with other
disciplines in a multitude of ways.
but a lot of what we do is somewhat
invisible if we're only considered to
be, task based helpers, but the real
beauty of nursing and primary care
is that we can engage in a fulsome
health professional practice that
includes autonomous management of many
conditions, diseases, and disorders.
Sarah: I just love the way that Angela
is able to so clearly articulate this
idea of the intersections of nursing.
Thinking about the distinction
between doctors and nurses,
what was your main takeaway?
Morgan: Well, it might seem a little
trite, the really important distinction
is that nurses don't practice
medicine, they practice nursing.
And I guess many people don't
make that distinction consciously.
and some people just think we
practice medicine, but nurses just
have a smaller scope than a doctor.
And thinking that would be wrong.
Sure, our scopes overlap at the
task level for a lot of things.
But if you just think about those tasks
I mentioned, Sarah, you missed something.
You missed that a value of having
a more diverse team and with people
approaching patients and patient
care differently from that medical
perspective and that nursing perspective.
And I think it's that seeing people
differently, that's what improves care.
We have to think about nurses
beyond the tasks that are in the
nursing scope and see that greater
value of nurses as a profession and
as a discipline in primary care.
And Sarah, you're an anthropologist,
so this probably makes more
sense to you than it does for me.
Sarah: I got so excited when we were
thinking about these ideas, Morgan.
You know, this idea that each
discipline brings not only the skills
or scope, but also the culture of their
discipline and their training and their
way of being and seeing the world.
I think it's There's so much
value in bringing in sort of
different areas of emphasis here.
And if you focus on disciplines as
complementary, in more holistic
care for patients and teams.
you can start to kind of build out.
How these distinctions work together
and why it's so important to have this
interdisciplinary team around a patient.
the medical anthropologist in
me keeps getting more excited.
We know it's not only really important
to value different kinds of knowledge
and experience, but what this highlights
is how complementary perspectives, can
then get embodied in the delivery of
patient centered care to really improve.
the quality of care, but
also the patient experience.
I think these diverse perspectives
just add so much here.
And I'm thinking about how
you've been framing this.
You said nursing profession, a few times.
I'm talking about discipline.
But what do you mean when you
say the nursing profession?
Morgan: Well, I'm not an expert
here and I'm definitely going to
be channeling Angela some more to
talk about some of that historical
development of the profession.
So I need Angela to help me out here.
Angela: nursing in Canada, or I
should say nursing in what is Canada.
It's today known as Canada because
of course, Indigenous people cared
for each other and themselves in a
multitude of ways prior to colonization.
But this colonial story of nursing in
Canada starts It's literally hundreds
of years ago with the arrival of women
from overseas, from Europe coming
here to establish caring agencies,
developing hospitals, building care
clinics, building public health
and community health centers in the
colonies that would later become Canada.
Morgan: And that caring
tradition in nursing continued
and brings us up to today.
Angela: today Nurses are self
regulating, autonomous professionals
who practice nursing, that is the
discipline we practice, the profession
that we practice, and we do so across
a huge range of environments, a huge
range of care settings, in what we
generally refer to as self regulation.
self regulation
Sarah: And this idea of autonomous
professionals, I think that's so key
and something that I didn't really
think about until we started diving
into the Nurse Compass Project.
And we'll link to that
resource in the show notes.
as autonomous professionals, I think
it means that nurses work within
their scope and can collaborate.
It's not just that they get
tasks delegated to them, right?
That's my understanding.
Morgan: 100%.
I don't think of nurses as someone
you should just give orders to.
Nurses are colleagues.
they have their deep tradition of caring.
They work autonomously, even
if it's in the next room or on
the other side of a curtain.
but they're also really good at teamwork.
And as I said, they sort of see
our patients in a different way
that I don't see our patients.
And I think that that
allows us as a team to work
Sarah: So it sounds like it's both being
able to work together and in parallel.
And I think I've seen that, you
know, with different nurses in
our workshops and in our own team.
Morgan: Yeah, exactly.
And Sarah Angela got a little deeper and
talked about the four domains of nursing.
And these start to frame that broad scope
of nurses as a profession or discipline.
Angela: and those domains are
clinical practice, which I think
is what most people think about
when they think about nursing.
They think about that nurse at the
bedside caring for you when you're
admitted to hospital, but we also
nurse or practice our profession in
education settings where we teach.
We practice our profession as researchers
in research institutions and as
independent researchers, and we lead and
provide administrative support and policy
leadership within the health care system.
Sarah: So which of these domains
do you think are relevant
to primary care, Morgan?
Morgan: Well, I think they're
all relevant to primary care.
I mean, obviously the bedside caring,
the clinical work of caring for
patients is what most clinics are
thinking about today when they're
thinking about hiring a nurse.
I actually have personal experience
in our team of nurses filling
every single one of these domains.
And as a little shout out, if you
don't mind, I'm going to shout out
to Hannah, who, I was just seeing
patients with yesterday on outreach.
so much.
And, delivering care, coordinating care,
but I've also got to work with nurses
in our clinic in the research capacity,
both, at universities, but in our
clinic, Karen and Roz have been running
studies and, really helped expand the
scope of our practice and teachers and
educators, nurses like Anne and Caroline
have a long history in our clinic of
mentoring new nurses in primary care
Sarah: when we think about the
educator role that nurses often hold,
I'm actually involved in the educational
program reviews for the BC College
of Nurses and Midwives, watching the
way that nursing leadership Volunteer
nurses who are part of these committees
sit down and really work through
sort of how educational learning is
structured and really paying attention
to how things are aligned across
the cultural aspects of care and on
continuous evaluation and learning.
I think those things really, come
to the forefront of my mind when
I think about what are the real
strengths that I've seen in this space.
Morgan: Yeah, that whole
considering how to educate nurses
as nurses is incredibly important.
The last one of the
domains is, leadership.
And our previous clinic manager,
Gray was a nurse and is a nurse.
nurses have been leaders
in many, many, many areas.
those are just examples from the people
that I've worked with at one clinic.
Sarah: And I'm guessing nurse
practitioners, get this, but I
wonder how familiar other family
doctors or primary care providers
are with these nursing domains.
Morgan: I'm sure many are
not familiar with them.
they weren't something that.
I knew about before myself.
But they remind me of our
own CanMeds FM domains,
Sarah: CanMeds is one of those things that
I hear about and nod all the time, but
I have no idea what they actually are.
Morgan: Well, in many ways, they're
a lot like the four nursing domains,
but in CanMeds FM, we have seven.
and I can never remember them all if you
say, well, what are these seven things?
I, you know, I only remember five
or six of them, but, Being a family
medicine expert, being a scholar,
being a leader, a health advocate,
Sarah: A podcaster, I'm guessing?
Morgan: I wish, I think you
have to put that one under
communicator or maybe collaborator.
I'd like to say maybe under
professional, but, I'm feeling a
little bit of like an amateur today.
so they're similar, right?
Even though they're broken
up in different ways.
, it's important to think that
again, but coming back to nursing
is nursing and medicine is but
those similarities are important.
And we can emphasize the differences
a little bit and here's Angela again.
Angela: nursing philosophically focuses
on, certain values that I think are
shared with other health professions.
those values do underpin
a lot of what we do.
And those values include things
like integrity, ethical care, but
they also include components like
social justice, which is a core
cornerstone of the nursing profession.
Morgan: When I talked more with other
nurses about why they might be interested
in primary care Nursing instead of the,
the hospital based nursing, I thought
I'd get answers like, ah, no more
shift work or it's easier on my back
Sarah: Which are probably both
true, and I'm guessing there's more.
Morgan: You know, what I heard first was
interest in caring for people who need
it and intervening before people were so
sick that they ended up in a hospital.
So the social justice and ethical
care, supporting people early who
needed it through the longitudinal
relationship based primary
care, those were more important.
When I asked instead of
just no more 12 hour shifts.
Sarah, I hope you hear some of the
similarities with family medicine, but
also pick out some of the differences.
Kacey, a nurse and diabetic educator,
who's worked in primary care
networks and is now one of our team
members at the ISU, talked about
primary care nursing like this.
Kacey: I think nursing as a profession,
is really kind of bringing in the, The
knowledge and the experience across the
board to provide care for patients it
starts with that relational piece of
getting to know the patient before we're
even looking at doing medical assessments
Sarah: And really, you know,
this sounds like relationship
based primary care to me.
Morgan: It does, and that's what I
mean by similar, but I think Casey's
perspective is also complementary
to primary care providers and
family doctors in particular.
Listen to how she highlights
some of what she would want to
learn about in a patient visit.
Kacey: And then it's doing
some assessment pieces.
both physical assessments and
psychosocial assessments, right?
So what does their physical body
look like and where are they living?
What is their access to income?
How is their education?
And then once we have a really good sense
of that, then we start moving into kind
of, okay, how are we going to support
this person in their health journey?
Sarah: But now you all do that, right?
Morgan: Yeah, I take a history,
I do physical exams, I assess.
But I don't describe it the same.
not quite.
I prioritize different things.
If you ask me, I might start talking
about why is the person here,
what's their reason for the visit?
Taking a medical history, getting
a differential diagnosis, ordering
tests, prescribing medications.
I mean, I also think about
supports and housing, etc.
But the emphasis for me is
just a little bit different.
Sarah, maybe a good example is just
yesterday at, clinic on outreach
with Hannah, who's a nurse that I
work with there and you're going to
meet her later, the way we talk to a
person, I might be asking a question
that feels very specific and, and
Hannah's one step ahead saying, I was
conferring with the housing staff, okay.
And you know, I wanted to coordinate
this other piece with you.
So there's this coordination component
that comes out first, this integration
component that comes out first, whereas
I'm trying to figure out how big is
the wound on their leg and, figuring
out which antibiotic to prescribe.
We'll land in a very
similar place together.
But the way we approach
it's a little bit different.
Casey gives another, broad
example, about this approach.
Kacey: it's a broad application of
really getting down to how do we
support people in either staying
healthy, getting healthy, or living
the best life wherever they're at.
Sarah: I totally get this.
Really, it's different emphasis, right?
But are we going to also talk
about, what things nurses can
actually do in primary care?
Morgan: Yeah, we'll spend some time
on it this season, talking around
some of the how and the what for sure.
but I, I did want to set the stage.
That nurses, like everyone, are not
just a reduction of the tasks they do.
I think that's really important.
They're team members, and they have
their own distinct and deep knowledge,
both professionally and individually.
I think the real value to patients is
having someone in a team with a different
role and a different perspective, and
that their own professional expertise that
complements what others do in the team
Sarah: And you know, we try to show
this in team mapping all the time.
and as you talk about this, I realize
how there's overlap and there really are
distinct scopes, but also areas of focus.
Morgan: so, Sarah, what do
you mean by areas of focus?
Sarah: Well, I think when we ask questions
like, how can we help this patient,
Andre, in team mapping, we use these
patient personas, simulated patient
cases to get teams thinking about how
they want to work together differently.
When we ask people, you know, how
can we help this patient, Andre,
first answers are often different.
Then we get to more common needs
and activities as we go along.
But.
The first comments come from nurses
are usually kind of more holistic,
more about, the background,
connecting with the patients, more
about understanding and advocating.
if you think about sort of the
answers from providers, they'll
look a little bit different.
And there's also the question of,
power and relationship that comes
into some of the team mapping and,
and the dynamics and the conversations
that happen around the table.
Morgan: So Hannah is a registered nurse
who works in primary care at Kool Aid.
And one of the days I get to
work with her on outreach we're
like a little outreach teamlet.
Hannah also does some urgent primary care.
Sometimes she has certified
practice in STI management, and
she's actually working on her
master's to be a nurse practitioner.
I interviewed Hannah for this
season and we talked about some of
the actual shared care that we do.
In this quote from Hannah, you'll hear the
value of different roles getting to that,
equity that you mentioned, Sarah, and this
is an effective way of supporting patients
and also changing some of those power
imbalances, be they perceived or real,
Hannah: I think there's also too,
this kind of power imbalance.
if I tell a physician something, is
it going to affect the medication I'm
prescribed or the access I receive?
Well, I think with nurses,
That doesn't exist as much
Morgan SM7b-MixPre: and I think,
Hannah, you can advocate in that
triangle of patient, nurse, and doctor,
you can advocate in a way that, a
patient might not feel like they can,
Hannah: Yeah, I won't say, Oh,
such and such asked me to ask you,
but I'll say, Hey, we were talking
and we thought of this idea.
Do you think that would be appropriate?
And then it's giving them a place that
they can ask, but without it being direct
Sarah: And, you know, I think that's
just really important, especially
for folks who might otherwise be
marginalized, who might need additional
support to advocate for themselves.
there are power and privilege
hierarchies at play, even if you're
trying to be patient centered.
Morgan: and also from a trauma
informed care perspective, I think
that nurses, both in training and
the role that they hold in the team,
bring a lot of support to patients who
experience that structural trauma of
medicine, even in the doctor's office.
Thanks.
Sarah, I think an interesting way of
highlighting the difference is to think
about the differences in diagnosis.
Nurses and doctors make
different diagnoses.
I have a medical diagnosis and nurses
have a nursing diagnosis, which is
Sarah: Okay, wait, so, how?
You get different diagnoses
for the same patient?
Morgan: Well, yes and no.
So, we don't get different diagnoses
in the sense that we Diagnose different
conditions, but our diagnosis are
different in focus, and that's the
difference I think that highlights
the overall approach and culture here.
Jamie, who's an RN and a
director at HQ PC, helps
understand the nursing diagnosis.
Jamie: So making that nursing diagnosis,
which is a diagnosis of a condition.
So saying a patient has urinary retention,
for example, it's not a disease.
It's a nursing diagnosis and then
making recommendations of how to
address that and What is needed next
Morgan: So I'm more focused on
the why of the urinary retention.
Like, why is it happening?
What's the underlying disease
process and then how to treat that
and a bit less on the other factors.
And when I don't have time, Sarah, it
then becomes my main or only focus.
Sarah: and I guess nurses will focus
more on the functional aspects for that
person as part of the treatment plan.
So to help care for health conditions
or symptoms that are impacting a
person's overall health, you need a
little bit more of that background.
Morgan: Yes.
Overlapping yet distinct from the
BC College of Nurses and Midwives.
They describe a nursing
diagnosis like this.
Okay.
Alan: A nursing diagnosis is a
clinical judgment of a client's
mental or physical condition.
Nurses make nursing diagnoses that
identify conditions, not diseases
or disorders, as the cause of
a client's signs or symptoms.
A nursing diagnosis is used to
determine if the nurse can improve
or resolve the client's condition.
Sarah: So again, I'm going to put
my anthropologist hat on here.
I like this because in medical
anthropology, we always talk about this
distinction between disease as a physical
disorder and illness as the experience of
that disease, recognizing that, experience
is completely influenced by culture
and expectations and social norms, as
well as Social determinants of health.
So, this focus on improvement
or resolution of the challenges
facing a patient really fits
into this, understanding.
And I think, you know, this idea that
nurses maybe focus more on the illness
experience, is an interesting area, and
it's helping me understand how these
distinctions broaden how a team can
better support a patient, bringing in
these different viewpoints into the care.
Morgan: Yes, sir, and I think they're not
just different viewpoints, but they're
overlapping with a different focus,
perhaps a priority, and that difference
is what makes the care that much better.
Sarah: Well, with that, Morgan, I
think we'd better wrap up this episode.
You know, it really helped me get a
glimpse into this distinction between
nurses and physicians and, really what it
means to be part of a nursing profession.
Morgan: Well, I'm glad
you enjoyed the episode.
I hope our audience did as well.
And thanks for listening everyone.
And if you have any questions
or topic suggestions, please
email us at isu at familymed.
ubc.
ca.
Michael,
Sarah: 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.