Subscribe
Share
Share
Embed
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.
Morgan: Are you wondering where
nurses fit in on primary care teams?
Are you interested in better
understanding the scope of
nursing practice in primary care?
Yeah, me too.
Sarah: All right, so Morgan, today
we're gonna focus on the role of
nurses in primary care, and I'm really
looking forward to this episode as
I feel like nurses are the missing
piece of the primary care puzzle.
You've worked with a few
nurses in primary care, right?
Morgan: Yeah, Sarah, I have, and I was
fudging a little bit with our opening
questions because I've been working with
nurses for years in primary care and
lots of different roles with nurses in
different teams in primary care over the
last two decades from in the clinic to
outreach to shelters, to mobile outreach,
out in streets and into tent cities,
I've worked with nurses in a whole bunch
of different settings over the years.
Sarah: But I'm right in thinking that for
a long time, kind of nurses in primary
care weren't very common, maybe, more
common in the community health center But
most nurses, what comes to mind is sort
of hospital or long-term care settings.
Morgan: Yeah, I think historically it
was more common that nurses were part
of primary care and then in, recent
decades it's been less and less common.
And so now we don't think of nurses
in a traditional family doctor's
office, we think of the family doctor
or a group of doctors and MOAs.
So you're right in that sense for sure.
Sarah: Well, it's interesting to
think about how it's evolved over
time and I think, nurses are able
to provide a lot of support and do a
lot of really important work of kind
of the caregiving aspect of care so
really wonderful that they're coming
back into this primary care space.
And I think that's one of the things
we've seen with primary care networks too
is a common role that folks are looking
at adding is the primary care nurse.
and One of the nurses we interviewed,
Janie, who we're gonna hear a lot from
in this episode, used the analogy of
like a tennis match to describe how
nurses support team-based primary care.
When a team adds a nurse, it kind of
allows full court coverage of patient
care, the additional bandwidth for
care that doesn't fall into the scope
of other team members like MOAs or
pharmacists, but that needs more
time follow up for frequent care,
which isn't always something that a
primary care provider is able to do.
So nurses can field both those longer
volleys, maybe spending more time with
patients who require more monitoring,
as well as those kind of short tips
over the net, the quicker triage of
care, wound care, immunizations, vitals,
urgent assessments, that kind of stuff.
So it's a really interesting
combination of those longer relationship
pieces and then the more acute.
Morgan: I don't play tennis,
but I like that analogy.
I think also the idea that nurses
are supporting expanded coverage
of the care from the team.
And scope of the nurse it overlaps a
lot of what primary care providers do.
It's a large overlap compared to
other roles that can join a team.
at least for the roles we have in bc.
Sarah: And we definitely heard
about the wide scope in our
interviews for this episode.
Today we're gonna hear from three nurses,
one nurse who works in two primary care
clinics and then we'll hear from two
nurses who work across both the primary
care and urgent care sides of a UPCC.
I hadn't really thought about how much
the setting a nurse works in is gonna
really influence not so much the scope,
because the scope of nurses I think,
stays the same, But what they actually
do, to support those clinical settings.
Morgan: Yeah, I think you're right.
The scope is there.
It's how the nurse and the team
work together and what parts of
the scope are being utilized.
So let's talk about some of the
things that are definitely in scope.
in my experience, there's some of
the basic things like taking basic
vitals, taking histories from patients.
Then you get into things like chronic
disease management, and that's both
the following of care plans, but also
the proactive recalling, chatting
with patients, coaching, doing
some of the assessments, providing
education, I think you mentioned it
earlier, around injections and other
preventive care, different screenings
for people of all ages really.
And then on the urgent side, nurses are
so good at triage, that you have this
whole other side of their scope of
practice that can be really valuable.
Sarah: And Morgan, I think I've heard
you say before, a nurse isn't equal
to a nurse, isn't equal to a nurse.
Right.
It also depends on what people are, have
experience in where interests lie, where
people might have taken extra training.
And that's, I think, really
important to recognize, not just
in the nursing role, but across
all roles in primary care teams.
So these are all part of
the nurse scope of practice.
Let's meet Janie Patrick, a
primary care network nurse working
in two primary care offices.
One large urban clinic with seven
physicians and one small rural
clinic with a single physician.
She splits her time across these
two settings and her role is
very different in each of them.
Here's what she says about her scope.
Janie: I'm looking at what the
physicians are up to and supporting
them in whatever way possible.
So that was the first thing I found
out about the job, is that I'm here
to support the physicians in practice.
so I looked at what they were doing and we
started with basic stuff like injections.
Things like that, that were time consuming
for them and very quick and easy for me
to just kind of slot in automatically.
The second clinic is more based on
chronic disease and more ongoing seeing
patients regularly for things like weight
loss support whereas, the bigger clinic
tends to be whoa, this needs to be done
today, this needs to be done tomorrow,
there's more kind of flying by the seat
of your pants in terms of what's ready
and what needs to be done, what doesn't.
Morgan: So these two clinics work
with Janie very differently, and I
think it's not just the size of the
clinic, but it's how they've chosen to
work together and what needs Janie's
filling in the different clinics.
Obviously in the larger clinic she's
filling more of an adaptable in
the moment to moment kind of role.
And in her second clinic, her
time is much more scheduled
with pre-booked chronic care.
Both of these work well and they can be
really valuable in different settings.
And actually Sarah both can
happen in the same clinic.
Of course, doesn't have
to be one or the other.
Sarah: So are you Both/Anding,
something right now, you know
that isn't making a decision?
Morgan: Right.
I know and I'm not suggesting,
starting with all the things because
it's hard to start doing everything.
Definitely when a nurse starts
and joins a practice, figure out
where is the most obvious need
and the best fit and start there.
So don't Both/And from the
beginning, but know that the
scope for any nurse is very broad.
Sarah: And we also hosted
a TeamUp webinar in March.
Suzanne Braithwaite, the President-Elect
of the Canadian Family Practices
Nurses Association alongside
Tannis Anderson, who is a clinical
nurse specialist for primary care.
And Melissa Rowe, a regional practice
leader from Interior Health's
professional practice office.
They talked about scope optimization
and role ambiguity, which is very
much this idea that the scope can
be really broad, but narrowing focus
in a role can also be really hard.
Highly recommend taking a listen to
this episode if this is something
that sounds interesting to you.
Morgan: Sarah, the role ambiguity
is something that we see
again and again in our work.
We always assume we know what each
other's supposed to do, we've worked
together in the hospital, during our
training or what have you, and so there's
often a lot of unspoken assumptions.
And then when there's overlap in what
we can do, if that's not cleared
up and the role is clarified, people
don't get to work the way they want to.
Sarah: One place where I think there's
maybe less role ambiguity, seems to
be urgent primary care centers, UPCCs.
I think this is partly because people
come from acute care often, and UPCC
teams are already really clearly defining
roles because they're working more like
an emergency room setting, the lower
kind of acuity of those urgent visits.
Morgan: And also Sarah, some
of it's the top-down design.
The urgent primary care centers in
BC are newer and so there's been a
lot of planning that happens with
the team in focus to start with,
and that top down approach has
helped with role clarity for sure.
And that can also be really important
when there's rotating staff, which there
can be for UPCCs with multiple shifts.
Sarah: And a lot of the folks we've
had the chance to connect with who
work in UPCCs have this kind of,
oh, I work in a couple UPCCs right?
Spence Newell works in this way.
He's a nurse in two UPCCs and he's
shared with us a bit about his scope,
which is again, really different
from what we heard from Janie.
Spence: I really enjoy teaching
patients something they weren't aware of.
I just like helping people and
when I see that there's actually
some mileage that comes from
that, I feel really good about it.
So, an example is when there were the
Tylenol and Advil shortages and we started
handing out resources that showed how
to take an adult dose of Tylenol or
Advil, crush it, formulate it based off
of your kids' weight and I think that
was really helpful for a lot of parents.
Yeah, It's a lot of triaging when
you're doing the urgent care side
of things and then some tasks as
well, calling patients about results,
follow up, that sort of thing.
During the primary care side of
things, it's a lot of intake,
talking about medications, sometimes
assessing them if they can't be seen
by their nurse practitioner that day.
And then a big part of it is those
intake visits and getting a set of
vitals and a brief quick history or
the reason for the visit before they
do see their nurse practitioner.
Morgan: Triaging can be a key nursing
task, but not just in the U P C C.
In community health centers and
regular primary care clinics it
can be really important as well.
I think nurses can do an initial
assessment of patients to determine
severity and help make decisions about
who they need to see and how soon, and
this can happen on the phone as well.
And this can really help the patients,
but it also helps the MOAs and other
clinicians so that the right people
see patients at the right time.
Sarah: Janie also talked about triage as
well but the kind of triage that arises
once you know a patient, once you have
that overtime assessment of how someone
is progressing and you can really identify
changing care needs for patients with
their primary care provider over time.
Janie: Every single day I hear,
oh my gosh, I'm so glad to
have the chance to talk to you.
I'm so glad to have the chance
to, air all the different things
I needed to talk about or go
through this and this and this.
And sometimes I'll hear things that are
quite shocking and I'll be talking with
the doctor, going, um, you know, this
is going on, did you know ? And then
it'll be like, okay, oh my goodness,
we better make an intervention here.
So it's very natural teamwork, where we
just cover for each other and really look
out for what's going on with the patient.
Morgan: And if you structure, the visit
and the team so that if there's a more
urgent need that expands, then a nurse
can be really helpful in sort of being
able to take that on during the day.
Sarah: And I think what we've heard from
all of the nurses that we chatted with
is that relationship focus is so central
to, their own enjoyment in their work.
Spence: the blended model is
interesting, cuz I hadn't worked
in urgent care previously.
If you've had a slew of urgent care
shifts to pick up a primary care shift
and just sort of be able to build those
relationships with patients and see people
again, and it's not just a turn style
or anything like that, you get to follow
up with them, see how they're doing.
That continuity of care is a lot of fun.
Morgan: So the relationship focus is
absolutely why I became a family doctor.
and I know many people in primary
care, that's often the driving
force behind their job satisfaction.
And it's important if you haven't done
team-based care to realize that being
part of a team doesn't impact that, and
in fact, it can strengthen my relationship
with patients because collectively
we're working and doing more for them.
Sarah: One of the things that came up
over and over again in our interviews
was the ability of nurses to observe
across the patient population and
identify specific gaps in care and
really find innovative solutions.
Janie has a great story about how
this really created opportunities
for her to think about working to
top of scope or in a different way.
Janie: I was noticing that I was seeing
a lot of elderly isolated people.
So I was the only seeing them because
they'd make it into the clinic to see me,
but there was nobody else seeing them.
I saw one, then I saw another one,
and then I saw another one and
I thought, okay, wait a minute.
You guys are all suffering
from the same things.
Yes you have, you know, we need an
injection or whatever, but you know what?
You're suffering from the same things that
you're isolated, so, I started a group.
And I'll just start a group and say, come
to the clinic, come on in and each other.
A very basic kind of social, come in
and say hello and let's hear your story.
And then I asked them if we could think
of ways to outreach to other elderly
people or other people that were isolated
at home, not necessarily elderly.
And so that ongoing group it's
an option for people to
connect in if they'd like to.
It turned out that those people are
connecting with each other way outside of
the group here, which was always my goal.
Morgan: the link between physical
medicine and the social care
needs is important for all of us.
And if that patient's booking multiple
appointments to help meet some of their
social connection, it really can stretch
the capacity of providers in the system.
We don't have the time, unfortunately,
to support patients to the
degree that they might need.
And so I really appreciated how
Janie was creative and found this
innovative way to support those patients
Sarah: Spence also shared an
example of noticing a gap in care.
At one UPCC they noticed that
sexual health was really something
that they were seeing a lot of
visits for and that wasn't addressed
elsewhere in the community.
And their UPCC took steps to fill that
gap by adding a skillset for nurses.
Spence: I do have colleagues who have
done the sexual education enhanced
certification for nursing, they're able to
diagnose STIs, test for STIs, treat STIs,
do pap tests, do counseling and I, think
it's been a really rewarding enhanced
scope of practice that we've gained.
For instance, the other day, one of
my colleagues, , we had seen a lot
of, I think it was chlamydia that day,
but five patients whom she treated
and tested and everything, and that
got to save them the whole waiting
to see a doctor, got to save them the
whole waiting for all these additional
steps and hurdles and obstacles.
Sarah: One thing we know from the
Team Up webinar on nursing scope of
practice, is that the scope of practice
for nurses is, large and some areas of
scope require extra training or skill.
Morgan: And I think there are certain
things that nurses will learn through
acute care that are directly applicable
and then there are some that aren't Sarah.
So preventive care probably falls more
into public health and primary care more
so than it does emerg, although certainly
people will try to squeeze in a little
bit of prevention wherever they can.
What did you hear from uh, the interviews
about how nurses are involved in
preventive care work in primary care?
Sarah: Oh, I have a really good
story from Janie about this.
She and the MOA in one of the clinics
reviewed EMR data and called in all
the hypertension patients who hadn't
been seen in the previous year.
the MOA phoned them, set up a recall
appointment, and they met with Janie
to do a review of how they were doing.
Through that process, they caught
a few patients who were at risk
for serious health complications.
Janie: Probably the biggest one of those
was a fellow who was a young fellow whose
blood pressure was so high that it was
amazing that he was even walking around.
He was quite enthusiastic and he
was about to hike way up into the
alpine region up in north of Whistler
and, the doctor and myself feel
that, he wouldn't have made it.
So he was, he just got the medications.
the hike got postponed and there's really
that kind of immediate feedback that
you see, which is rewarding for sure.
Morgan: So preventive care,
often it has to fall to the
bottom of the priority list.
We have to respond to the urgent needs
and the chronic care needs of patients,
and I think this has a huge potential
for the role of nurses in primary care
teams and using EMRs to define those
patient groups and then get them to
come in and see a nurse is a great team
activity to boost the quality of care.
Sarah: So let's talk about
nurses as part of teams.
Janie talked about her role in
anticipating the needs of primary
care providers and trying to
always remain open to jumping in,
Janie: I guess that's the key
right there, is the attitude.
My attitude was from every
single day okay, how can I help?
How can I help with this situation?
How can I help with this patient?
What's going on with you?
What's going on with your day?
It's just being aware, like paying
attention, being adaptive, seeing what
needs to happen and anticipating, wow.
I'm gonna be able to help with that.
Sarah: One example that I heard that I
really wanna share is about how teamwork
happens in practice at a clinical level.
So Janie shared an example of
working with a social worker and
a primary care provider and why
it was so different than simply
referring patients between providers.
Janie: I'll be seeing the patient
and oh my gosh, you need the social
worker, I can help you with that.
So I will, Talk to 'em a little bit, get
the background, find the reasons why I'm
feeling that they need the social worker,
you know, there's a reason And what I'm
doing then is providing the social worker,
with the background of what's going on
here, you know, so that they can just come
right in and go straight to the problem
and be that much more effective as well.
And actually the person that we
saw last Thursday, we both went
in to start with and then I could
provide for the patient, that feeling
of team care is really happening.
And they, And they saw both of us together
and I said, is it okay if I tell, the
social worker, a few things about you?
And it was like, yes, absolutely, please.
And so I could provide the
history quite concisely.
And , the patient was listening,
going, that's good, yes.
I was verifying with him.
And yeah, so it was really, very
effective, very effective.
Now I can keep an eye on that
patient and check in with patient,
as well as the social worker.
if I notice something or they reach out to
me, automatically have this person right
at my shoulder , knows the patient, knows
the situation, knows the history, knows
everything, and I can go, oh, you know,
he's having difficulty with this and it
takes a minute for me to do that, and then
she'll reach out to him and say, oh, I
heard you're having difficulty with this.
And you know, it's like that ongoing
teamwork, that is reaping benefits.
Morgan: Being part of a great team
has been one of my favorite parts
of being in clinical practice.
It's been so important and
I totally agree with Janie.
Being able to hand off a patient in a way
that cultivates that trust, sustains that
continuity and enhances care is fantastic.
It reduces so much friction for
patients and then improves their
experience of care overall.
And you know, with a team,
that really also improves our
experience of delivery of care.
Now, I say that because it's important,
but also Sarah, it's not all roses.
We know that teams can work
well and they cannot work well.
We've seen lots of nurses
join and then leave practice.
Everybody needs to be ready when bringing
on a nurse into a primary care team.
And I think that change management,
that making sure there's the
right space is so important.
From the nurses you talk to what are
some of the things that we as primary
care providers should be thinking about
when we're adding a nurse into our team?
Sarah: Well, the first thing I think is
to think really carefully about what the
team wants the nurse to be able to do.
. Janie: So I feel like when I started,
if I had known a little bit more about
what could happen or what, was already
expected of me or what was already
some good ideas that would've helped.
We figured it out as we went along and so
having a kind of a list or a quite defined
idea of how the physicians would find it
helpful, having that communication ahead
of time, that would be really helpful.
Spence: I think maximizing
that scope is so helpful.
A small example is just in the time that
I've been working at the two urgent care
centers, we're now allowed to do ear
flushes, which are very easy, very simple,
but it saves the patient a lot of time not
having to wait to see a doctor, a nurse
practitioner, if the registered nurse can
do it, sort of with the the PCPs blessing.
Maximizing that scope, getting them
comfortable with phone calls, calling
patients, cuz there's a lot of follow
up on tasks and that sort of thing.
Morgan: So maximizing the scope over
time I think is really important.
And if nurses aren't comfortable
getting into primary care because
they haven't worked or trained in our
clinics before, starting with a scope
that they are comfortable with, if
they're an Emerge nurse doing more
triage, and if they have been working
in a diabetes education center doing
more chronic care and education.
And then build that scope over
time, through training, but
also just through shared care.
And maximizing scope takes time, sarah.
I remember back in our clinic we do
a lot of H I V and Hep C treatment,
and over time the nurses have really
taken on a leadership role in this,
particularly with our Hep C programs.
I have to say not only has our capacity
increased because of that, but the
quality is dramatically increased.
Hep C treatment has of course changed
dramatically over the last 10 or 15
years, but how we do it in our practice,
we couldn't have changed the way we have
without our nurses who just, talk about
maximizing scope, they're running the
program, they're recalling patients,
they're following through, they pull
out physicians occasionally when they
need to, but most of it's done and led
through the nurses, which is fantastic.
Sarah: Well, and I think I'm starting
to feel like a little bit of a broken
record here, but we really have heard
from just about every professional
that we've spoken with this season
about the real importance of working
to build trust and investing, in
developing as a team, creating those
spaces for people to work together.
We spoke to Erin Williams, who's a team
lead in one of the UPCCs that Spence
works in, and she had this to say,
erin-williams---she-her-_1_03-15-2023_100817-2:
advice to them would be to really
spend time building trust as a team.
Once you build that trust, it allows
you to be able to be vulnerable with
each other and being able to lean into
the different team members' experience.
One thing that I've found is just
each team member has such a wealth
of experience and it's all varied
and broad cuz we all come from
so many different backgrounds.
I think though, What's important is
when you can build that trust with each
other that you're not afraid to say,
I actually don't know much about that.
Can you share?
And that person really be able to share
that and then it really helps celebrate
each other's strengths in that, we all
have different strengths, different
things that we've learned along the way
that's wonderful to be able to share.
When we first started, we were given like
three weeks to come together as a team.
And in that time, I got to
facilitate creating a team canvas.
So we wrote this team canvas of our
goals and visions for the clinic, how
we wanted to support the community
that we served and some actionable
items and then how we wanted to be
as a team and interact as a team.
And so in setting up these guidelines or
defining how we would interact as a team,
I think were really helpful cuz it was
the team that created these, you know, one
was to find joy and play in our workplace.
One was to treat every interaction as
the other person was well-intentioned
and to be well-intentioned in
every interaction with each other.
I think it's great to be able to
set expectations and define norms
within a group of how you wanna
be and how you wanna interact.
Morgan: This is just so
foundational to team-based care.
Sarah: so the third thing that
we really wanna highlight is
the importance of being ready to
communicate about things that go well.
And, you know, things that don't go well.
Create opportunities for
teams to reflect together.
Learn together, and then, you
know, maybe change practice.
Morgan: so let's recap.
What are the key considerations
for nurses in primary care?
Sarah: Nurses have a huge possible scope
of practice, and there can be real value
of honing in on specific care areas, so
chronic disease, preventative care, urgent
care, specific patient populations It can
be really valuable to narrow the scope
and what's most needed in your clinic, and
then build up from there as a first step.
Morgan: And then encourage nurses
to find care gaps and generate
innovative solutions to fill them.
they're a wonderful member of the
team and they've got some fantastic
ideas about how to improve the care.
Sarah: And I think, if you structure the
work so that nurses have opportunities to
build those relationships with patients
and with the team, that really feeds
into the other two recommendations, right?
if the relationships are there,
nurses can identify the gaps because
they're connected to the patients.
If the relationships are there,
they're also able to identify those
areas of interest or areas that they
might wanna dive into first in terms
of, specific focus areas for scope.
Morgan: Absolutely.
And with those three things to wrap
up, that kind of wraps up this episode
on nurses and primary care teams.
Thanks for listening to this episode
of Team Up, and join us next week
when we talk about another role.
Sarah: And we'd love to hear from
listeners as always, so drop us
an email at isu@familymed.ubc.ca
with any ideas or things you'd
like to see in future episodes.
Thanks for listening.