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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 planning on hiring a
nurse into your primary care team?
Are you not sure about the difference
between licensed practical nurses and
registered nurses in primary care?
Yeah, me too.
Morgan SM7b-MixPre: Sarah, in this
episode, I want to take some time to
talk about registered nurses and licensed
practical nurses and how their roles are
similar and different in primary care.
by way of a little tangent though,
before we jump in, I was just working
yesterday with two different nurses
and one who had been an LPN for
several years and she just went back
to complete her registered nursing.
And so I just wanted to shout out to
Tessa, who finished her exams just last
week and is now a fully fledged RN.
Sarah: Oh, that's so exciting.
So, guess the reason behind this episode
is we know now that BC clinics can
apply for funding to hire registered
nurses or licensed practical nurses
through the nurse in practice program.
I'm curious about how clinics are going
to choose which one they're going to hire.
Morgan SM7b-MixPre: Sarah, it's not a
simple question to answer, I don't think.
it's a lot about fit.
And, what the expected scope of
work is in a new team, if you
haven't already established a team.
And ultimately, what's needed to
support patients in your practice.
what that support is and how you're
going to share it across a team is
really the question we need to answer.
Sarah: you just always try to hire kind
of the most qualified nurse that you can?
You
Morgan SM7b-MixPre: Well,
I'll answer that in two ways.
I mean, I think yes, there's
definitely a need in primary
care for certified practice RN.
So well trained, nurses with
expanded scope of practice.
But I'd also say no, if, you're
not going to use somebody with
that level of training and, their
practice scope is actually smaller.
So it, depends.
Practices can work through some
questions as a group to understand
what that scope is going to be.
That will help guide them.
Sarah: And I guess, of course, human
resources also comes into this.
What's available, wherever your
team is, is going to be a factor.
Morgan SM7b-MixPre: Yeah.
That's a really good point.
Sarah: So, for today, how can we
start to unpack this for primary
care clinics in this podcast?
Morgan SM7b-MixPre: Well, so this
episode, let's, sort of start with
how to think about LPNs and RNs and
how they fit differently in a team.
And then we can maybe highlight
that with some clinical examples.
and then Sarah, I I know this is
supposed to be about LPNs and RNs,
but I want to digress a little bit.
And, also remember that,
that nurses are people too.
And it's about getting the
right person who's a good fit
to work with you in a team.
And before I go any further, I'm
using LPN a lot, for licensed
practical nurse.
LPN is what I've been used to saying for
so long, but LPN is not the same in every
province and, what we're talking about is
a diploma trained nurse and they do have
other titles in other, jurisdictions.
Ontario uses the,
registered practical nurse.
Which is an RPN, which just to
confuse me, is the same acronym as
Registered Psychiatric Nurses in B.
C.
Sarah: never knew that.
And I have totally been
confused by that in the past.
So thanks.
And why aren't we talking about
registered psychiatric nurses?
Morgan SM7b-MixPre: Well, I don't
think it's actually funded in B.
C.
for a Registered Psychiatric Nurse, in the
Nurse in Practice program, so I thought
we would just stick to what's funded.
that could change, of course, and,
we could probably do a special
episode on Registered Psychiatric
Nurses in the future if that changes.
Also, I haven't worked in primary care
with any registered psychiatric nurses.
Sarah: That would be really interesting.
And I know from my experience on
the Educational Program Review
Committee BC for RPNs, that they're
so in demand right now, and there
really aren't many training programs.
That's probably why there aren't many
examples of RPNs in primary care.
So many of them are working in
focused mental health practices.
And I think with LPNs and RNs,
really have enough to get into today.
let's start with thinking
about the key differences.
How can we distinguish between licensed
practical nurses and registered nurses?
Morgan SM7b-MixPre: right.
Yeah.
So let's dive in.
So I think to start, both
are regulated autonomous
professionals trained in nursing.
They are nurses.
the LPNs have a diploma.
So they, were trained through a diploma
program and RNs have a bachelor degree.
many have gone back for extra training,
so, you know, extra specialized skills.
There are certified practice
programs for RNs and some of them
even gone back for other degrees,
like a master's degree or, or even a
PhD.
Sarah: Morgan, I'd like to know
more about the clinical scope
differences in primary care.
Morgan SM7b-MixPre: So first, Sarah,
it's important to note that the
scopes actually changed over time.
Jamie from HQBC, she was an LPN before
she became a critical care nurse.
And, she talked about how she had much
less autonomy, previously as an LPN.
And that's actually what I'm used to
working with LPN several years ago.
And so it was a key distinction for me.
And LPN needed much more patient specific
orders and they had less autonomy.
Sarah: but this isn't the case today.
Morgan SM7b-MixPre: No, not so much.
I think the LPN scope in BC has changed.
I mean, even this year it's shifted.
so, you know, always check with the
nurses and nurse practitioners of BC and
the nursing college to confirm scope.
But I've had to kind of relearn
this a little bit, and I think that
the key difference is that LPNs are
really focusing on people who are
stable and predictable patients.
Angela Wignall, who's an RN and
the director at NNPBC, she has
both an RN and an LPN in her
family.
Sarah: I can imagine there are many
dinner table discussions around
some of these differences there.
Morgan SM7b-MixPre: Yeah, I think so.
But the way she describes an LPN
to other people is in this way.
Angela: They're diploma prepared nurses.
Some of them may also have specialization
training like wound care or, and they are
really focused on providing care to all
populations, but to folks who have stable
and predictable health trajectories.
And that's a really important statement.
There is some resources online
through our college, BCCNM, about
what stable and predictable means in
the context of nursing regulation.
But that's really what the scope
of LPNs, is constructed around.
Sarah: Stable and predictable, is
that suitable for most primary care?
Morgan SM7b-MixPre: I actually think so.
And I know that you and I have talked
a lot about My unstable practice,
but there's actually a lot of
predictable and stable care in most
offices in primary care, particularly
around prevention, education,
chronic
Sarah: So the LPN can really build
relationships with people and
help with the more stable care.
And that I guess would give capacity
to the family doctor or the nurse
practitioner to focus more on the
unpredictable or acute cases that kind
of come into the primary care team.
Morgan SM7b-MixPre: Yeah, exactly.
And as long as there's a clear
clinical pathway for the LPN.
So if there is some instability,
the LPNs can use their clinical
judgment and escalate when needed.
That works.
Sarah: And RNs then can they assess and
manage the more unpredictable cases?
Morgan SM7b-MixPre: absolutely.
Their scope is broader.
Angela: And we can care for both stable
and predictable patients on those
kinds of health trajectories, but we
can also care for complex, unstable,
and unpredictable patients, which is
why you often see registered nurses
across a wide breadth of acute care
settings because they are optimally
positioned, for some of those roles.
Sarah: So then which nurse
is best for which practice?
Morgan SM7b-MixPre: I think
Sarah, that the team has to really
think about the role they want.
To add into their team and then
fit the nurse as a person and
as a professional with that role.
I don't think it's a pick an
RN or pick an LPN, you know,
answer for all of primary care.
Sarah: So you want a good match
in scope and skills and interest.
What kind of nurses do you work
mostly with in outreach, Morgan?
Morgan SM7b-MixPre: Well, I actually
work entirely with RNs at Cool Aid.
things can be much more unpredictable.
and I think RNs manage
that with more autonomy.
So it makes sense for Cool Aid.
And actually in Cool Aid, all
of the nurses either have or
are getting additional certified
practice beyond just being an RN.
So it's, sort of shows the level of
scope and autonomy that we need in our
practice.
Sarah: Can you tell me
what certified practice is?
That's something that I
don't know anything about.
Morgan SM7b-MixPre: So certified
practices is additional training and
there are number of specific training
modules that nurses can take from.
Opioid use disorder to, first call, S.
T.
I.
Treatment contraception management.
I'm probably getting all the
names wrong and remote practice.
And these all give additional
scope and training for the
nurses toe toe work within.
And we actually have a range of nurses
with different certified practice our
Sarah: I'm also guessing if your practice
wants a nurse to work with stable
patients who need good care but can't
get access, then an LPN working with
your team could be a really good fit.
I can see that would be a great
way to build up relationships with
patients and get help advocating
for patients when needs change.
So Morgan, can you give me some
more specific clinical examples
as kind of our second topic here?
I think I can hear our
audience asking for that.
Morgan SM7b-MixPre: Yeah, let's do a few.
we'll probably get into some more
the next couple episodes as well.
But, let's first if we think about
providing education to patients,
either one on one education visits
or in a group, I think in general,
much of the common education can
be provided by either LPN or an RN.
and if you're wanting more sort of
custom curriculum and custom curriculum
design for your clinic, around
specific topics that are relevant in
your practice or in your community.
RNs might be more comfortable doing
that, as that's more often in their
scope than an LPN, but both can provide
education.
Sarah: What about something more
focused on a specific clinical
condition like supporting patients
with say high blood pressure?
Morgan SM7b-MixPre: Yeah, I think that's
a good way to distinguish the differences.
So, both LPNs and RNs can support
patients with high blood pressure.
They can do an assessment.
They can do a nursing diagnosis.
They can provide
information and education.
They can, of course,
check a blood pressure.
They can encourage blood pressure
monitoring at home and review the results.
And they can engage with patients
and discuss medications, side
effects, check adherence, all that.
Sarah: But if the patient
comes in and their blood
pressure is suddienly too highh
Morgan SM7b-MixPre: So then an LPN would
be, perhaps initially assessing and
realizing that the patient's unstable
and consulting more quickly with the
primary care provider, and RN would
likely manage that, more autonomously.
So as a family doctor, I think
I'd want to be sure I had a little
bit more capacity in my day.
So that I could work more closely with
an LPN for those unexpected, consults
that might happen a little more often.
that way we're working
more closely together.
Sarah: Okay, so give me one that
highlights the scope difference even more.
Morgan SM7b-MixPre: Okay, so that's easy.
That's triaging.
And I think this is very much in the
scope of an RN, so triaging something
that is coming through the front door and
you don't know what's going on, but it's
not really in scope at all for an LPN.
by definition, if someone's coming in with
new symptoms or an acute exacerbation of
something that was chronic and stable,
they're no longer stable or predictable.
So.
Fevers, a new cough, an injury, new
symptoms of a urinary tract infection
or an STI or something like that.
Those are all, either
unstable or unpredictable.
And I think that's where the RN's
skill set, sort of shines through.
Sarah: if your practice wanted a nurse to
be the first point of contact for things
like fevers, coughs, and stuff like that,
you know, the RN would have that in scope.
And you'd want to make sure that the nurse
had time in their day to see the fit in
appointments that are going to be needed.
Morgan SM7b-MixPre: yeah, exactly.
so if the primary care provider,
the family doctor or the nurse
practitioner, Likes more that
variable flow in the day, then an
LPN actually might be the better fit.
But if it's the reverse, and
you're wanting the nurse to do
more of that, first call kind of
response or, you know, first visit,
then an RN is the better choice.
Sarah: So I think I get it now.
You're coming back to the idea of
stable and predictable patients as a
key way of, thinking about scope here.
And for RNs, if they only worked
with patients who were stable, they
wouldn't be working to full scope and
it might not be rewarding for them.
Morgan SM7b-MixPre: Yeah, so I
think it's not only better for our
patients, but then it becomes more
interesting for us as individuals to
work more closely to our full scope.
And ultimately, as you know,
Sarah, this means better team
dynamics and better team retention.
I think this also brings up
another, part of scope that, that
Jamie from HQBC flagged for me,
which is more about the team.
RNs are often in team leadership
positions, so this is less clinical,
but I think it's important to highlight.
They can.
Coordinate the team.
Jamie: The other piece that I don't
think is highlighted with the registered
nurse is their leadership roles being to
be In a leadership role as a registered
nurse and supporting the team environment
and supporting other disciplines, other
professionals that work within that team.
Morgan SM7b-MixPre: So Sarah,
that's another thing to think about.
Especially, I think, with a larger team.
If your practice integrates more
closely with other services, like
in a smaller town, or you've got a
larger team that you've got to manage.
RNs tend to have more experience in
leading care planning, coordinating
teams, coordinating projects, that sort
of
thing.
Sarah: That's a really good point.
And thanks, Jamie, for putting
that out there so clearly.
RNs are really more used to taking
on that facilitator role, and that
would include coordinating and running
huddles, planning in kind of a quality
improvement context as well, right?
Morgan SM7b-MixPre: Yeah, absolutely.
and also coordinating care across
the community in and out of
hospital is a good example as well.
that coordination is really important.
And, and again, by definition,
patients are usually not
stable when they're going in.
And because they're coming out of
hospital, there's another unpredictability
when somebody comes out of hospital.
So a great place for our ends to work.
So, Sarah, are you ready
for an advanced team move?
Sarah: Oh, sounds exciting.
Morgan SM7b-MixPre: team, think
about our ends working with LPNs.
RNs and LPNs work together all the
time, we're kind of thinking right now
about having a nurse in a practice,
but I think it's actually a really
good thing to think about in a larger
practice that there are multiple nurses
working together and having the LPNs
working with more stable patients.
And, you know, if things are getting
a little bit unstable, that they can
talk to the RN who can then triage and
coordinate care as necessary, provides
a really interesting additional
component of the team where family
doctors and nurse practitioners then.
Are really working to their full
scope and there's a lot more
access across the whole practice.
Sarah: Great.
So, I have one more question
for you, and this goes beyond
the LPN or RN, scope discussion.
We talk about this when we work with
growing teams all the time, you know, the
idea that it's not all about the tasks
or the nursing position, it's about the
person, their experience, their interests.
Do you agree?
Morgan SM7b-MixPre: I agree 100
percent and Sarah, we can't wrap this
up without acknowledging that we're
each more than the initials after our
names.
Sarah: Right, so we've got to get
not just the roles on the bus,
but the right people on the bus.
Morgan SM7b-MixPre: Yeah, exactly.
We want to work with people who I
think are diverse and compliment our
skills, but it's also that balance
of getting people that fit with
how we want to work and that's sort
of that general approach to care.
Yeah.
the general approach to
how we work together.
And nurses like doctors and nurse
practitioners and MOAs are all people
with a wide range of experience
and personal interest and skills.
Jamie: some nurses would have
more comfort and competence.
with pediatric patients and
others with death and dying and
others with chronic disease.
And so I think it's recognizing that
through experience, additional education,
and just job experience, we bring
various attributes to our practice.
Sarah: And it feels right that Jamie
should get the last word for this episode.
Bring the right person onto your team.
Morgan SM7b-MixPre: Yeah, I agree.
It seems like a good
place to wrap up today.
So if you're planning to hire a nurse,
think about the fit of that person on your
team as well as their training, the scope,
the skills and interests that they can
bring to support your patients and augment
care.
Sarah: And there are a lot of other
resources out there to help once you
get into the specifics for your clinic.
In BC, the Family Practice Services
Committee has their new Integrating
a Nurse into Practice program
Morgan SM7b-MixPre: And the nurses
and nurse practitioners of BC
are also developing their nursing
initiatives for primary care.
will help with effectively
integrating nurses into
practice.
Sarah: And then, of course, we also
have, team mapping workshops, both
with the Innovation Support Unit
and with many of the coaches in BC.
There's a whole host of resources
online through teambasedcarebc.
ca, Plus, there's the Nurse
Compass, which we co designed and
we talked about in episode one.
Morgan SM7b-MixPre: And the Nurse
Compass was designed to help clinics
get tangible examples for primary
care visits that can be shared
with nurses of different training.
So it fits well with today's
Sarah: All right, Morgan, everyone
listening, see you next time on Team Up.
Morgan SM7b-MixPre: Thanks
for listening to the team up.
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.