S07 E11 Nurses in Primary care and Mental Health

In episode 11 of TeamUP!, Morgan and Sarah explore the significant role of nurses in aiding patients with mental health needs, particularly mood disorders, in primary care settings.

The hosts discuss how common anxiety and depression are, and how nurses' skills in connecting with patients are vital in providing comprehensive care. The conversation covers the different scopes of practice for Licensed Practical Nurses (LPNs) and Registered Nurses (RNs), and how these professionals assess and support patients with stable and unstable mental health conditions. Featuring key quotes and anecdotes from nurses in the field, the hosts look into the importance of team support, debriefing after stressful events, and the need for escalation pathways when patients require care beyond a nurse's scope of practice.

Special Thanks

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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
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TeamUP! Season 7 Episode 2: Nurses as a Profession — How nurses augment primary care

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: Are you curious about
how primary care nurses can help

patients with mental health needs?

Yeah, me too.

Morgan, you wanted to talk about nurses
supporting patients with mental health

concerns, mood disorders specifically.

Why highlight this one?

Morgan TLM103 MixPre:
lots of reasons, Sarah.

I think first, it's common.

I recently read a paper that
anxiety was the number one reason

for visits in primary care and
depression was in the top ten.

So, mood disorders are common and
something that I think nurses can

definitely support in primary care.

I think it highlights something
that nurses, a lot of nurses are

very good at, which is connecting
with patients and providing support.

and some of us docs might not think of it
when we think of a nurse joining our team.

We think of a nurse helping with
more medical chronic illness.

Sarah: Right.

And I actually think, you know,
when we've done a lot of our mental

health focused primary and community
care mapping sessions, we often hear

that patients need more support.

they need more time with clinicians, but,
you know, really, it's that coordination

piece, where, people are looking for more
support and really looking to kind of,

you know, pull teams together around.

And I think nurses have those skills when
you think about the coordination that's

needed around mental health supports.

Morgan TLM103 MixPre:
Absolutely, they absolutely do.

And there's actually more
nurses in mental health than

psychiatrists in mental health.

So nurses have a big role to play, both
in mental health services, but also in

the mental health care in primary care.

Sarah: And then there are, of
course, registered psychiatric

nurses as well, or RPNs.

but those nurses really work right
now, at least, in mental health

care settings, not in, primary care.

We haven't, seen as many nurses working
in primary care mental health in our work.

Morgan TLM103 MixPre: Yeah,
and that's true, Sarah.

I think there's a few reasons for
why we haven't seen so many nurses in

sort of, primary care mental health.

I think mental health in Canada,
it's been more multidisciplinary

historically with more defined roles
for nurses like case management.

And so we see more nurses in that
space and secondary care, the

registered psychiatric nurses.

They're definitely more in mental health,
secondary care than in primary care.

And then I think the last part is that
it maybe it's hidden a little bit that

nurses in primary care are more likely
to be generalists just like I am.

And so they do mental health as
part of their practice while doing

lots of other primary care as well.

So maybe it doesn't get
highlighted as much.

Sarah: So let's talk about some of the
things that nurses do in primary care

to support people with mood disorders.

For thinking about supporting
a patient kind of with stable

symptoms, stable anxiety, or stable
depression, how can nurses help?

Morgan TLM103 MixPre: Sarah, I think
all nurses can support patients with

mild or, stable mental health issues.

Remember from episode two that
LPNs, their scope is focused on

stable and predictable patients.

Angela: They're diploma prepared nurses.

And they are really focused on
providing care to all populations,

but to folks who have stable and
predictable health trajectories.

Sarah: That was Angela Wignall from NNPBC.

So all nurses can support patients with
mental health concerns to varying degrees.

Morgan TLM103 MixPre: Yeah, so I
think all nurses have a similar

approach to assessing people
with mental health concerns.

Casey, who's a diabetes education
nurse, and she's focused

more on medical conditions.

Even though she said she was less
comfortable with mental health, her

approach is pretty comprehensive.

Kacey: They would sit down with
the patient and they would have a

conversation and they would assess them.

So they would ask questions
about their mood and about

what's going on in their life.

Has this happened before?

How have you coped with it in the past?

Did it work?

Did it not work?

So a lot of that almost not motivational
interviewing, but just finding

out assessing where they're at and
then determining does something

need to happen now or can it wait?

Morgan TLM103 MixPre: When I heard
Casey's approach, it's familiar and

reassuring for how to assess and
support somebody with depression.

Sarah: And so I'd like to talk about
scope and comfort for a second.

Going back to what Angela said.

An LPN is focused on stable patients.

Some RNs are less or more comfortable
with mental health conditions, depending

on kind of their own experience and
where their practice has been focused.

What if a patient was stable or
thought they were stable, but then

all of a sudden they come in and
you realize that they're not stable?

then what happens?

Morgan TLM103 MixPre: I think this is a
really good question and we think, well,

that's why you would always hire an RN.

But, but remember that we're all
health professionals and we know

how to work within our scope.

We know what our competencies are.

So I'd expect an LPN, for example,
or anyone who felt that they were

out of their, their competency, that
they would reach out for support.

So they could consult the physician.

Or the nurse practitioner down the
hallway, or an RN on the team, and

then they would summarize what they've
heard, what their concerns are, and

then bring the team around that person.

Sarah: Of course, that totally
makes sense, and I think, you know,

mental health is one of those areas
where I anticipate you would see

some more of that fluctuation of
stability when people are coming in.

Morgan TLM103 MixPre: Yeah, so
Hannah, an RN who I work with,

as most of our audience already
knows, we do a fair amount of

mental health work in our practice.

and there are several things that
Hannah does all the time with

our complex patients, whether
they're stable or unstable.

Cool.

Here's Hannah.

Hannah: the

mental status exam can really
highlight for a nurse who's

really acute, and needs to be seen
promptly, or expedite a referral to

a psychiatrist if there's actually
underlying layers of other diagnoses.

or current suicidal ideation or
self harm, you know, I think nurses

are great at getting collateral
and historical information.

So, instead of the provider having to
go through PowerChart to see if there's

been psychiatric emergency visits or,
um, MHSU progress notes, a nurse can

go through and get that collateral,
and do that mental status exam.

Sarah: So this is a great example
of how a nurse can pull together

information as part of the team.

Hannah mentioned assessing who is
really acute at particular times.

And this kind of leads
me to my next question.

Who triages more acute mental
health issues in primary care?

and I guess, how do you know,
before you go triage sort of

if someone is in that space?

Morgan TLM103 MixPre: Yeah, it depends.

I think RNs and registered
psychiatric nurses, they triage.

they assess people in mental health
crises regularly, as can nurse

practitioners and family doctors.

So if it works in your team,
registered nurses are well

positioned to triage in primary care.

Here's Jamie from HQBC.

Jamie: Yeah, it's a role
for the registered nurse.

The role of the RN is being able to
assess that newly diagnosed anxiety and

again, looking at that holistic picture
of what's going on, why is this happening,

validating, and just hearing from the
patient so it's not this power distance

between a physician and this client
or patient who's probably has anxiety,

even coming in to talk about their
anxiety and recognizing that it's okay.

And having that, I guess just the
discussions to lower the stress

and supporting the patient to be
able to disclose to the physician

Sarah: I imagine that power distance that
Jamie's talking about might limit what

some people would be willing to share.

Morgan TLM103 MixPre: I think it
can, Sarah, and, personally as a

physician, it's always hard to hear
that, but I, think it can be true.

Sarah: Well, and I just think there's,
so much built into the history

of medicine and nursing that just
reinforces those kind of power dynamics.

so what happens for a nurse if a patient
is too sick or if they, you know,

need a medication, then what happens?

Morgan TLM103 MixPre: Well, like
with all of us, we need to have

appropriate escalation pathways.

Here's Angela from NNPBC on that.

Angela: So if a nurse needs to escalate
care, the trigger for that for us is

it, the patient requires something that
is outside of our scope of practice.

We usually will create for
ourselves referral processes

for what that looks like.

So in the context of a primary care
clinic, it might be as simple as, popping

your head in to the office next door and
saying, we've reached that threshold, I'm

tagging you in, and physician colleague,
this is where you step in and shine.

Morgan TLM103 MixPre: And sometimes we
have to reach out beyond our primary care

teams to support our patients as well.

Angela: It may also include
external escalation.

So if there are concerns about
immediate harm, of course, we have

duties to report, we have all of
those same legal requirements.

So in some instances, and I would say
rarely, and we aim to keep it low, we

may need to call in other resources
like, transport to a tertiary care

center with higher levels of mental
health care available to them.

Sarah: That sounds kind of stressful.

It's, not something that I deal
with every day, that's for sure.

Yeah.

Morgan TLM103 MixPre: And thankfully
it's not something that most people in

primary care deal with every day as well.

Sarah: Well, and I think that
kind of leads well into my

next area of kind of questions.

Let's, talk a little bit more
about support and debriefing

when things do get, escalated.

hearing about your practice, Morgan,
and all the stress people are under,

especially I think post pandemic, we're
seeing more and more of these kind of

high levels of anxiety in primary care.

How do you get support when situations
are super intense and things

Morgan TLM103 MixPre: Sarah, there's at
least two ways that teams can support each

other, at least the way I think about it.

The first one is in the moment, during
that intense encounter, that And

that's one way that teams really shine.

I think at Kool Aid we
do this all the time.

Even if we aren't having to call
paramedics in, Hannah and I are

talking in the moment, debriefing.

And here's Hannah about a
recent encounter we had.

Hannah: I think of

an example of us at the
supportive housing building

Morgan TLM103 MixPre: it was actually
in a hallway in the building, and

our patient didn't want to move.

So he was so unwell,
we just kept him there.

Hannah: We had a young gentleman who
was in, acute mental health distress,

and, complex substance use trauma,
and he was having some auditory,

delusions, and we really worked as a team

Morgan TLM103 MixPre: So we were
supporting our patient while

supporting each other in the moment.

We were actually tagging each other out,
to check a chart or get a medication while

the other person stayed with the patient.

Sarah: And I imagine that would
have been really hard, if not

impossible, to do if you'd been alone.

Morgan TLM103 MixPre: Yeah, I think if
I was alone, Sarah, I would have just

had to call for help because we were
both there, we could help our patient.

And they didn't have to go to hospital.

Sarah: What's the other way
that you support each other?

Morgan TLM103 MixPre:
The other way is, after.

So debriefing after a stressful
event, as a team lead.

Angela: It's also attending to us as human
beings because those residual impacts of

witnessing somebody in a dire situation.

Morgan TLM103 MixPre: That's Angela again.

Angela: They're very real.

We carry them with us.

I'm sure we can all immediately think
of and name folks we've cared for that

come to mind as soon as, you start to
say, Hey, I needed an intense debrief.

We have that person in
our mind immediately.

So we carry those we care for with us.

And, having that opportunity to
be human together in a debrief is

really important part of healing.

Sarah: I know we've talked about how a
team creates this structural resilience,

and this is something I love thinking
about, you know, having people to share

with, to lean on when needed, just
knowing kind of that you have other people

around you that you can reach out to,
and people who can step in if needed.

I think we know that this is, so important
when we think about minimizing burnout

and supporting provider wellness.

We know right now that, you know,
providers are, very strained, so anything

that we can do, I think, to enhance these
kind of supports, it's just so valuable.

This is a really good example of where
a team can kind of step into this space.

Morgan TLM103 MixPre: And Sarah, the
debrief doesn't just have to be about

a mental health crisis, obviously.

I mean, that's what
we're talking about here.

But they can be so important for lots
of different reasons in the day, and

throughout your day in primary care.

anything that either of you are
holding on to, that you need to

help sort of shake off, you know,
we all take on more than we should.

And that's just a way for us to debrief
and process a little bit as a team.

Sarah: And I think a good team can
really help support you there, right?

Morgan TLM103 MixPre: Absolutely.

Yeah.

Sarah: Okay, Morgan, so this has
been, you know, a really wide

ranging and, interesting discussion.

What's a key takeaway
for our audience today?

Morgan TLM103 MixPre: I think just
talking about the mental health

escalation procedure for each of you,
that's an important first step, even

if it's just, when are you going to
pop your head out of the room and ask

for help and make sure that you, both
know when you're asking for support.

so then the other person
knows to respond and come in.

Sarah: I think that you mentioned,
you know, for each of you, sometimes

you need support in the moment too.

It's not a, one way thing.

Morgan TLM103 MixPre: A
hundred percent, Sarah.

so I think, when working as a
team compared to when I did solo

care, that's what I really missed.

And Sarah, for you, what stood out?

Sarah: Well, I think, thinking about
team resilience, so, the escalation

procedures like you mentioned, but also
de escalation and creating the space

for teams who have, you know, have built
those relationships and who know each

other, to make it safe to debrief and
make it part of your routine as a team

to really enhance resilience and, help
with, you know, minimizing burnout.

Morgan TLM103 MixPre: Well,
Sarah, that sounds like a good

place to wrap up this episode.

Sarah: It does.

See you next time.

Morgan TLM103 MixPre: Thanks for
listening to Team Up, and if you have

any questions or topic suggestions,
please email us at isu at familymed.

ubc.

ca.

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.