S07 E04: Being an Employer - Multiple Hats and Thinking About Clinical Policies

In this episode of TeamUP! we learn about the complexities of being an employer of a primary care nurse within smaller private clinics.

Our hosts, Morgan and Sarah, discuss the complexity of being both a clinical team member and an employer, emphasizing the need for clear clinical policies and role definitions. Major topics include the challenges of holding multiple roles, the impact of power dynamics in teams, and the importance of transparent organizational policies. They also provide practical advice on creating clinical workflows, drafting policies, and leveraging nurses' skills for better team integration and patient care.

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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BCCNM Controls on Nursing Practice:

This is an infographic that highlights the four levels of controls on a registered nurses’ practice. https://www.bccnm.ca/RN/ScopePractice/part1/Pages/controls.aspx

RN Suturing Decision Support Tool for BC:

This document is a detailed decision support tool to assist registered nurses working in British Columbia.https://www.clwk.ca/get-resource/treating-minor-uncomplicated-lacerations-adults-guideline/

BC Guideline (just updates July 2024) on COPD:

A scope-guide document that provides recommendations for how to interact with a person with chronic obstructive pulmonary disease.

https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/copd

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: Do you want to learn more about
being an employer of a primary care nurse?

Do you want to learn more about
how to support nurses on a team?

Me too.

So Morgan, what are we
talking about today?

Morgan SM7b-MixPre: Well,
Sarah, this one's important.

It's about being an
employer in primary care.

And I think smaller private clinics.

Are becoming small teams now, and that
means the doctor, the nurse practitioner

is often the owner of the clinic.

And that's also the employer of a nurse

Sarah: And I know in BC, many of
the primary care network nurses were

actually hired by health authorities.

Now I get that this is shifting
new funding and I understand

that difference, but we want to
focus on team based care here.

Morgan SM7b-MixPre: Yeah.

So hear me out.

This is important because I think although
people are used to all the normal employer

functions like HR and tracking hours and
paying staff and stuff, think having them.

Nurses in your practice that you're also
the employer for changes the dynamic

in the team, and the employer has to
consider things like clinical policies,

different controls on practice, that
you wouldn't have to do as a, clinical

colleague, and this needs to be documented
as the nurse is brought onto the team.

And we'll dig into this, but it
definitely helps with scope of practice.

And without thinking about this, think
you can really limit what nurses can

do in your practice and on your team.

So I thought we should
spend some time on this.

Sarah: Right.

this is something that I knew
nothing about until we dove

into the Nurse Compass Project.

And, there we really talked
with the Nursing College and

the Nursing Association in B.

C.

And they described four
levels of practice controls.

So first, there's, legislation
and regulation, then, of

course, college standards.

And then we get down to
organizational policies, and

finally, individual competencies.

Morgan SM7b-MixPre: Right.

And it's these four levels and these
are common across multiple professions.

It's not just for nursing, but
I do suspect that family doctors

haven't thought so much about
the organizational policy level.

Sarah: Mmm.

Morgan SM7b-MixPre: and people also call
this the employer level controls and not

being clear, On what's in your scope of
practice impacts how you can work together

if it's not clear at any of the levels,
but particularly at that one, you end up

doing a lot more with patient specific
care plans or patient specific orders.

but if you have clear organizational
policies that enable nurses to

work more autonomously within their
scope of practice, you have more

independence, safe practice, et cetera.

Sarah: So that, dual relationship,
especially kind of beyond the

usual HR things, really does impact
clinical care, which is something

I don't think I understood before
we started getting into this.

So can you tell me more about this?

Morgan SM7b-MixPre: Yeah, I intend to.

Let's talk about a couple of things.

So the challenges of having multiple
roles, I think we just need to

name that and how to manage that.

So we'll talk a little
bit about that today.

And then let's go through some clinical
examples from nurses about how clinical

policies have helped them in practice.

And then lastly, we can talk a bit
about the work involved and who

can do that work for creating these

policies.

Sarah: So this sounds a lot more
interesting to me now, and I think it

might be useful for other clinic employers
like community health centers as well.

Morgan SM7b-MixPre: Yeah,
I definitely would be.

So let's dive in.

Sarah: So Morgan, we spend
a lot of time thinking about

roles and role clarity in teams.

Thanks.

You wanted to start with the
challenge of, having multiple roles

in the context of being in both an
employer and a clinical colleague.

I'm really interested in this and
particularly about, you know, how

it changes power dynamics in a team.

Morgan SM7b-MixPre: Sarah, when
I, started, I didn't really

think so much about roles.

I just thought, I'm a doctor
and I got to do my work.

But over the years, I realized that
there are multiple hats that we wear

and then we have different roles , and
the more hats you have, the trickier

the relationships can be within a team.

And I think that's an
important thing to just sort of

name.

Sarah: And I know the anthropologist
in me is always coming back to

power and authority and ingrained
hierarchies in health care.

But, you know, the fact that it's
physicians who are often owners of

these clinics, there's this power
over in, patient medical homes that I

really think needs to be acknowledged.

How can we manage that best in teams?

Morgan SM7b-MixPre: Well, Sarah, you said
at first, like acknowledging or naming it.

I think that's important just for
everyone to say, yeah, this is a

bit of the reality of where we are.

and then I think defining
the different roles.

and being explicit about those
roles and accountabilities.

And we talk a lot about roles
and accountabilities in our

team, but I think that's

important.

Sarah: And I think, you know, it's
that transparency and responsibility.

So you don't just know who's responsible
for what, but you also know when

someone is working within a particular
role and when they're, you know,

shifting from their clinic owner
role to the clinical colleague role

Morgan SM7b-MixPre: And that, keeping
the roles separate, it might seem really

silly, but I think it helps a lot.

and it can be as simple and
straightforward as having simple,

separate times and separate
meetings for the different roles.

We're seeing patients right now.

We will talk about, how the clinic's
working and holiday schedules, et cetera,

at a different point in the week or
a different point, even in the day.

the other way to keep
the pathways separate.

So don't as a nurse, don't sort of
send, I'm going to be really simple,

a holiday requests in the EMR.

Technically, you could, and, conversely,
as, the owner, don't use the EMR to send

out, messages that you'd, same way you
would send out a message about falling up

on a blood sugar or something like that.

So keeping things separate
just really helps make it all

clear for everyone.

Sarah: So I get the, level of,
holiday schedules and, raises as, as

employer roles, but I need some more
kind of clinical descriptions here.

How are these roles different for, care?

Morgan SM7b-MixPre: Yeah.

Okay.

So I'll try.

So as a, family doctor, as a primary
care provider, I might give a patient

specific order, or I might write down a
care plan after I'd seen a patient, and

I'd put all that in the electronic record.

Okay.

you know, this could be directed to
a specific team member, yeah, I'd

also do things like as a primary care
provider, I'd be participating in

the daily huddles, case conferences,
and that's all wearing my doctor hat.

But as an employer.

Which to be fair, I'm not the employer
in our community health center.

I, just have the one hat, but I would be
responsible for us having the policies

for how to manage patients policy would
describe the care flow overall for

the clinic with the specific limits
and the different escalation pathways

and, defining some of the scope for
different roles of different training

levels, not specifically for people.

Thank you.

And then, all that I would put into a
policy folder, electronic or physical,

I don't know, but, you know, it
would all be part of that employer

role,

Sarah: So this all needs
to be really organized.

And I feel like you just set up kind
of for the next topic in this episode.

Morgan SM7b-MixPre: maybe a little bit.

Sarah: So, uh, Let's start with examples
of an organization's clinical policy.

I need to know what you mean and
why this is important to patients.

Morgan SM7b-MixPre: Okay, again, I'll try.

So as a family doctor, primary
care provider, I would give

that patient specific order.

So let's say I've got a patient with,
COPD, so chronic obstructive pulmonary

disease, and they have an exacerbation.

They come in with a new cough
and shortness of breath.

And if I see that person, I might
give an order to do a peak flow before

and after giving them an inhaler
and, ask the nurse to, manage all

those things with that patient and
come back to me if there's no change

within

five

minutes.

Sarah: So very, very doctor, doctorly.

Morgan SM7b-MixPre: Yeah, exactly.

But as an employer, I'd be responsible
for us having a clinical policy.

now that could describe when the
RN can administer, salbutamol,

that inhaler autonomously.

And it could talk about, you know,
if a patient comes in with shortness

of breath, who do they see first?

So the whole clinic knows.

there could be some signs
and symptoms in there.

for when to trigger escalation.

And then that gets applied to
all the patients in the future.

There's definitely a
clinical component to that.

But it's the policy part of
it that just gets applied.

Holistically going
forward, that's important.

Sarah: Okay, so that's really
helpful, I get, and particularly

with the shortness of breath example.

Like I know that that's one of
those things that you would have

to have kind of clear, guidelines
around how, the clinic works.

But can't nurses do a lot
of things in the policy?

Morgan SM7b-MixPre: Well, it's in scope.

and if they have the specific skills,
then yes, but they often need the policy

to enable the application of that scope.

So I said clinical policies that
they're not patient specific

orders or patient specific care
plans, but they're clinic wide.

And by defining that process,
they actually help nurses work

to their maximum scope and really
work as independently as possible.

So I started to think of these
as some of the guardrails

and the escalation pathways.

Okay.

then nurses know where they can safely
work and what's within scope and the

context of where they're working because
that context of where they're working

can sometimes change and shape the,
what they can do in that particular

practice.

Sarah: So these, guardrails
and escalation pathways.

Should be different depending
on training and the individual

competencies of specific nursing roles.

Morgan SM7b-MixPre: Right.

So, licensed practical nurse,
compared to a registered nurse with

remote certification in BC have very
different scopes of practice at, The

other levels, personal competence,
college level regulations, et cetera.

So if you think of all the four levels
of nursing control and practice, you're

going to have different levels of, scope.

And in primary care, we're
thinking about that third level

of the employer level control.

Jamie: Yeah, I think a good
example would be suturing.

Morgan SM7b-MixPre: So that's Jamie from
HQBC and a former intensive care RN.

Jamie: So suturing is within
the scope of practice of a

nurse, with additional training.

And so it's making sure that the nurse
that you hire has the additional training.

It's making sure that the nurse has
the escalation pathways in place to

be able to perform that activity.

Sarah: So with the right employer clinical
policy, a nurse could do suturing.

Morgan SM7b-MixPre: Well, in BC, RNs
have the scope, the ability to suture

uncomplicated lacerations in adults,
if they have the personal competencies

and official links and decision
support tools will all be in the show

notes.

Sarah: And in a primary care
clinic, As you know it, you may

decide, that, the suturing is part
of the nurse's practice or not.

Morgan SM7b-MixPre: Yes.

Yeah.

So you can decide in the practice,
what part of the scope Is

appropriate and could be applied
in the office and what parts might

not be

Sarah: So, you might say, you know,
you're only using steristrips for

lacerations and only suturing is being
done by the NP and, or the physician.

Even though, theoretically, the RN
could, but your policy says, in our

clinic, we're going to do it this way.

Morgan SM7b-MixPre: a clinic
could definitely decide that and

then put that into the policy in
the workflow with that example.

if a nurse starts to suture when the
clinic isn't expecting it, then there

could be lots of confusion, even
if it's something that they've done

elsewhere.

Sarah: And even if it's something that
the patient wants, or something the whole

clinic wants but hasn't talked about,

Morgan SM7b-MixPre: Yeah, I mean,
often it's maybe not the whole clinic,

but it's almost the whole clinic.

And so not being clear across
the team can cause frustration,

confusion, sometimes even anger.

So, having clear formal and even
clear informal policies builds

trust in the team and that trust
propagates to patient trust as well.

Sarah: And I just keep thinking, you
know, how great would it be within

a clinic to have a space where you'd
collect kind of policy related questions

so they could be easily answered as,
by people as they come up, right?

Morgan SM7b-MixPre: Yeah.

Yeah.

I think that's, an important thing
to have is cause it's going to come

up if you haven't worked together.

or if somebody new comes on the team,
you change a person, you change the team.

And then you might want to ask,
is there a policy around that?

And sometimes it's like, well,
that's how we always did it.

But the new person doesn't know that.

So I think that's really
an important thing to think

about.

Sarah: Well, and then
how do you get policies?

We know a lot already exists in this
space, and I think nothing's a bigger

waste of time than reinventing the wheel.

Where can clinics get example
policies and workflows for nurses?

Morgan SM7b-MixPre: Sarah, I'm not sure.

I've only found a few examples for

primary

care.

Sarah: I thought you found like a pile of
templates and examples for the show notes.

No?

Morgan SM7b-MixPre: I thought so too.

I found some, a bunch for
acute care, of course, but

relatively few for primary care.

I started looking at decision support
tools, called DSTs, but I actually

misunderstood what nursing DSTs are, and
Angela from NNPBC helped set me straight.

Angela: Decision support tools or
DSTs are formal, and I think that

that word is really important because
DSTs tend to be something that are

required through a regulatory mechanism.

DSTs are not generally what we refer
to as the kinds of clinical guidance

that you would describe as clinical
practice guidance or care pathways.

Sarah: So, decision support tools
are more from the college and

regulatory related groups, not just
something that a clinic can draft up.

I didn't know that.

Morgan SM7b-MixPre: Yeah, neither did I.

And this was so helpful because I kept
thinking of decision support for me is

something that I could write into my EMR
or I could take a guideline and modify it

and create little workflow in my office.

but actually, this is, different.

I double checked with Angela,

So, as a practice, I'm not making DSTs,

Angela: Generally, it would be unusual
in a primary care setting to make a DST,

Morgan SM7b-MixPre: but but I might.

make a policy.

Angela: you definitely
make a clinical policy.

In fact, I hope you would.

Morgan SM7b-MixPre: And
so Sarah, that leads us to

Sarah: making clinical
policies and workflows.

Morgan SM7b-MixPre: bingo,

Hannah: We have.

Standing orders or workflows.

And I think those are so
important, because it protects.

The provider, the nurse,
also the patients, and it's

aligned with the policies.

So, if I'm ever unsure, then
I can check in with that

Morgan SM7b-MixPre: That was Hannah.

Regular listeners will know that
I get to work with Hannah, a

registered nurse, every Thursday.

And she also picks up shifts
at some of the local urgent

primary care centers around town.

Standing orders and workflows
are important, with more

rotating team members for sure.

They're also great for cohesive

teams, too.

Sarah: I can really see different value
for both types of organizations, actually.

Morgan SM7b-MixPre: Yeah, there's
definitely value for both.

I think it can be great for a new
nurse in a practice to take the

lead in developing some of these.

Then that comes back to your question
earlier, where do you get these?

As an autonomous professional who
knows their personal scope and their

professional scope, I think a nurse
is in a great place to start to

draft these, clinic level policies.

So they're an obvious
person to help build these

out.

Sarah: And I'm guessing that a new team
member might also have the time to do

this as part of their getting started.

as the clinical demand is
maybe slower at the start,

Diana: Each team has the opportunity
to really define what they want that

to look like, and as they bring more
nurses into their teams, they can also

define what that will look like in the
scope of caring for their patients,

Morgan SM7b-MixPre: You
just heard from Diana.

She's a registered nurse and
a master's co ISU this summer.

She comes from a nursing background,
almost entirely in acute care, but has

been interested in exploring what it
means to be a nurse in primary care.

Diana: and so as nurses join these
teams, I do think that They can engage

in some of these discussions and
really say, you know, I really love

working with this particular patient
population or I really have a lot of

good skills in education and teaching.

I want to be involved
in some of that work.

Let me spearhead some of those
initiatives at our primary care setting.

So I do think that it is a great
opportunity for nurses to Act with more

autonomy, to really take advantage of
some of their strengths and their skills.

And bring those as assets to the
team that they're working with.

Morgan SM7b-MixPre: And I think as
nurses are communicators and coordinators

as part of their professional
identity, they can facilitate

the review of clinical policies.

Hannah also suggested that this is
actually a great time to work together.

Hannah: there should be like times
where a nurse and the employer

who's also a provider, can sit
down and create workflows together.

Because a lot of the time I
feel like workflows are created.

without considering or having
feedback from the people who

are actually doing the work.

So having time set aside
to create those workflows

Sarah: So, what she's really talking about
is working together on working together.

Morgan SM7b-MixPre: Yeah.

Teaming up,

if

you

will.

Sarah: And we have a
tool for that, don't we?

Morgan SM7b-MixPre: We

do.

Sarah: Well, that's a great
place to wrap this up.

Hot takeaways for the audience, Morgan.

Go!

Morgan SM7b-MixPre: Okay, I'll give
you one, Sarah, as a primary care

provider and an employer, separate
those roles, just start making that

sort of a habit and policy, make the
times different, make the meetings

different, label the communication.

if you want to make it totally explicit,
you can just label your emails.

What's your takeaway for this episode,

Sarah?

Sarah: Let me think, uh, the one
I like, if you're a nurse joining

the practice, put it out there that
you can be a point person, take on

the role for drafting some of those
common clinic policies and workflows.

You know, as a new nurse, this is
a great way to introduce how you

like to work as well as getting
that out there to your new, team.

Morgan SM7b-MixPre: I really like that.

And I think that's a great
place to wrap up today.

So thanks everyone for listening and
we'll see you next time on team up.

Sarah: If you have any questions
or topic suggestions, please

email us at isu at familymed.

ubc.

ca.

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.