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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.
Morgan: Are you interested in learning
more about nurse practitioners?
Do you want to know about how
they work in a primary care team?
Yeah, me too.
Sarah: So Morgan, in this episode
we're gonna dive into the role of
nurse practitioners in primary care.
And I'm excited to learn as we go
here in our work in different kinds of
clinics across bc I've had the chance
to learn a lot about the scope of nurse
practitioners, but I think the general
public is maybe less aware of the
details when it comes to their role.
Morgan: Sarah, you're probably right.
, I've had the luxury of working with
NPS clinically, but not everybody
has, and not all patients have.
now with nurse practitioner led clinics
in some of the communities, that knowledge
in the public is probably on the rise.
But there's definitely questions
that we keep hearing in discussions
focused about what is the role,
what's different for nps, nurse
practitioners, , and the different kinds
of teams that they can be a part of.
Sarah: So let's dive in.
What is a nurse practitioner and what can
a nurse practitioner do in a team Morgan?
Morgan: So a nurse practitioner
is a nurse that's had additional
training and in primary care, they're
usually primary care providers.
They can be trained and have other areas
of focus, in different parts of the
healthcare system but we're just gonna
focus on the family nurse practitioner.
They bring their skill and their lens
to patients in primary care generally
as that primary care provider in much
the same way as a family doctor does.
And given that overlap of skills
and the different kinds of
service, I think that's the
confusion about what is an NP add.
Well, most of the time, NPs, as I
said, they're primary care providers.
They can also be working in a
team with family doctors, working
more closely with a subset of
patients within a shared panel.
And I think that was one of the
first, , NPS that we met Sarah
five years ago, in the ISU.
Sarah: Right.
And I think as we went out and talked
again to a range of providers to
create this episode, the added value
that NPS can bring to a team was
returned to so often by many of the
voices that we'll hear from today,
Morgan: yeah, so rather than thinking
about the role it was replacing a family
doctor , or being a cost effective
alternative, I think the NP should
be thought of as complimentary and
addressing needs in the system overall.
And then that means increasing
access to primary care in a
whole bunch of different places.
And, that's what the system
in our patients need right now.
Sarah: So what can nurse practitioners do?
Morgan: Right.
So as a primary care provider, nurse
practitioners, they can diagnose
and they can treat at a high level.
Sarah: And they can also
prescribe medications.
Morgan: Yep.
So it includes that as well as supporting
patients with acute primary care needs.
Sarah: They can do things like set
simple fractures and dislocations, right?
Morgan: Yeah.
And that was news to me, because I don't
do that as often as I used to and of
course, I think place we all think of
initially is chronic disease management.
So the more routine follow up.
Sarah: And I went back to the
guidelines to actually learn that.
So we'll put a link in the show notes to
the scope of practice guidelines from
the BC College of Nurses and Midwives.
What else can they do?
Morgan: So , they can refer
as a family doctor would to
specialists and other providers.
and they can also do other procedures,
like inserting IUDs and removing lesions,
lumps and bumps and things like that,
with training , and the equipment,
they're able to do all those things.
Sarah: And I think really to reiterate
where you started us off, Morgan, is
this idea that nurse practitioners
could be very autonomous primary care
providers who provide primary care.
Eliza: Well, I would say that or scope of
practice when you zoom out and at things
We have very expanded scope of practice.
Everything from, as I said, medical
assistance and dying to methadone
prescribing, to providing trans care,
to all the care that is required
to meet the primary care needs of
complex populations are within our
scope, but that there also can be some
variability between NPSs, depending on
the practice that they're working in
and the populations that they serve.
Sarah: And the idea that Eliza Henshaw
highlights here is that in primary
care there are different clinic models
that NPS can fit into, and the roles
that they take on are influenced by
the model of care they operate under.
Now, Eliza's been practicing as a
nurse practitioner for over 14 years,
and in this time she's worked in a
number of different kinds of clinical
settings in mostly urban communities.
Sydney Richardson-Carr is a
nurse practitioner who works
in two urgent and primary care
centers in the interior of bc.
Sydney: We don't need , any oversight.
We're very autonomous in our practice
and we can provide all kinds of care.
So any care through the lifespan
from infants to older adults and
there are nurse practitioners, around
the province working in primary
care, but lots of NPs work in acute
care settings, specialty settings,
some outreach and rural settings.
So we're really, we have a
quite a broad range of NPs
doing lots of different things.
for me, working at the UPCC sites,
definitely providing that classic
primary care when you think of
someone coming in with a health
need, you know, what's going on?
what kind of interventions do you need?
So we really can provide that well-rounded
primary care to patients of all ages
Morgan: So Sydney works in, as you
mentioned, Sarah, the Vernon, U P C
C and U PCCs are set up differently.
And in this U P C C, the NPS provide
a range of primary care services from
those urgent assessments straight
the way through to longitudinal care.
Sydney: We do the long-term primary care
just like you would at a regular kind
of family practice clinic, just with the
benefit of having all of the team members
and then we also do the urgent primary
care, meaning it has to be a concern that
needs to be addressed within kind of a
12 to 24 hour period that should be able
to be managed in a primary care site.
Sarah: What stood out for me in all
the conversations we had was really
this full scope of practice idea for
nurse practitioners in primary care.
Erin: So, as an NP in my team,
I provide primary healthcare.
So I go to clinic in the morning and
my patients are booked to see me and
or talk to on the phone, and I manage
all of their needs throughout the day.
So with primary healthcare, there
can be, you know, managing chronic
disease, there can be managing mental
health, substance use disorder, helping
support frail elderly stay in their
home, helping support and maintain like
health promotion for babies as they
come in for their well baby checks.
I provide women's healthcare.
I do various procedures like inserting
IUDs so it's very much a full scope
practice of primary healthcare.
Morgan: Erin talks about
the full scope quite a bit.
And I think this emphasis on full
scope probably comes from some of
the common misconceptions that people
have about what NPS can and can't do.
And nps, they've been practicing in BC
for a while, but with the increase in
training spots and the rollout of the NP
clinics, We're definitely having a lot
more, attention on the role of NPs in BC.
Sarah: I think you're right Morgan.
And, still, when I asked the
nurse practitioners we talked to
about surprising parts of their
scope, the full scope conversation
was definitely reiterated.
Sydney described often seeing
this with her new patients.
Sydney: people would say,
Oh, so I'm seeing you.
I'm not seeing a doctor.
and my response would be, oh, well,
you know, you actually don't need to
see a doctor today because I'm going to
provide you with the care that you need.
And so then we would proceed with
our visit, and I would, assess their
medical concern, make a diagnosis,
treat their concern using, you
know, , a prescription or other, um,
non-pharmacological treatments and
they would be very pleasantly surprised
and, you know, carry on their way.
And that's really what it's all about.
The biggest surprise is just
someone realizing that they can
get all of their primary care
needs from a nurse practitioner
without having to see someone else.
Morgan: Well, the NP role is different.
They're primary care providers,
Sarah and, it does take people
a bit to get used to that shift.
Sarah: I think the doctor idea
is so ingrained in our like
primary care mindset, right?
Morgan: Yeah.
And nurse practitioners are nurses
through their training and their
previous experience, and I think
that's important to recognize.
Now, some patients do, as Sydney
highlighted in her story, being
a nurse also brings a different
lens, I think, to some of the work.
it makes nurse practitioners particularly
focused on whole person and functional
care, and now I think a lot of us do
that as providers, but it's definitely
a strength I've seen with nurse
practitioners that I've worked with.
I've seen this particular focus and
desire to really take the time to
understand their patients, the personal
context, the social determinants of
health, and how that influences their
functional health and wellbeing.
Kelvin: I think the areas that I think
we've excelled in, especially in British
Columbia, , is for, uh, op opiate therapy
for safe supply, for medications to meet
the needs of British Colombians facing
a toxic drug supply that's out there,
for HIV prevention and HepC treatment.
We've been on the forefront on these
lines as well, and providing that access
when others have felt uncomfortable.
So me and my colleagues you
know, we're working with the
BC Center for substance use.
We train a lot of NPS and physicians
to be able to prescribe medications to
support harm reduction and to decrease
the the opiate crisis hopefully.
Sarah: And that was Kelvin Bai an NP
who works in an urban CHC in Vancouver.
And I know we've already talked
about how community health centers
are really purpose built to meet the
needs of the populations they serve.
And they're so well positioned
to do this with an equity lens
in the work, often focusing on
otherwise marginalized populations.
But Kelvin and Eliza both reflected
on the specific abilities of NPS with
their nursing background to really do
exactly what you just said, Morgan, to
focus on that patient-centered care.
Kelvin: NPs are really well poised
because of our nursing background to
work in teams because, for example,
like the other day, patients come in
with me with their taxes issues or
they're living in modular housing and
they don't know why the government's not
giving them a certain benefit or they're
not allowed to access I have no idea.
But then it's like I sent a message or
work with my community health support
worker and the social work team, and
they're able to get patients, you know,
the money flowing so that they could
buy groceries so they have money to eat.
And so I think those are the things
that we get excited about as nurse
practitioners about team-based care,
when the funding is supporting that to
meet the social determinants of health.
As an NP I love that about my
scope and that we are poised
well to work with teams.
And then we really see that we want to
have an equitable, give voice, I guess
give power to those other team members
so that they could actually, feel an
equal part of the team, to share the
load and to share the decision making.
Eliza: I think there's a growing
awareness across the board of the
importance of the social determinants of
health, especially as we've seen these
inequities become so prevalent in so many
populations after Covid and with poverty
and multitude of other complexities.
We can just see this gap getting more
and more alarming as we move forward.
And many providers would agree that
there is a fundamental need to shift
the way that we deliver care from
quantity and volume to quality and value.
And that aligns really nicely with our
nursing backgrounds because as nurses,
we really strive to meet patients
where they are, to involve patients
and their families as equal partners,
and to move towards patient centered
care at an individual and a team, and
an organizational and a systems level.
Sarah: And you know, so often when we
ask nurse practitioners about their
favorite parts of their jobs, it was
the stories of being able to really
provide individualized care, and often
working with other team members to
provide that care really well in a
very patient-centered wraparound way.
Kelvin: so some of the simple, somewhat
silly wins, the other day the L P N that
I worked with on outreach was we were
able to get them a raised toilet seat.
Because this person had a brain injury
following an overdose and had mobility
issues and couldn't go to the washroom.
And then the other thing as big as
getting someone healthcare coverage, or
preventing someone from being deported.
so it goes from like small
wins of a raised toilet seat
to big, like bigger ones.
My ideal day is just, even just small
wins or someone just thanking us that we
took the time to listen when no one else.
.
And if we have these, we hold onto
it so preciously because we're
being pressure to attach more
numbers or, to see more people.
But we have to pause.
It's about that pausing and say like,
we did it today for that one person.
Morgan: So there's that joy
in the little things that you
can do to support patients.
and for many of us that desire to
help, to support, I mean that's,
that's why we do what we do.
It can be a little thing like being
able to syringe somebody's ears and
suddenly allow them to hear that
can be a total game changer.
I think things like that are
what drive so many of us.
Erin: it's being able to see a patient
who may have been in emerg multiple
times for the same thing and they've
come to you now and it's your initial
appointment and you're able to spend
that time to understand really what's
going on and the reason behind why
they're going to emerg for the same thing.
and them feeling validated that the
care they're asking for is important,
and then building that rapport and
having that trust and that person
trusting that you are listening
to them is also super rewarding.
So those are like just little things.
It's, yeah it's the relational pieces
I think that are quite rewarding.
Sarah: The building of relationship
over time is something that
Erin really emphasized over
the course of our conversation.
She also highlighted the
relationship centeredness as a
key motivator for her in her work.
She spoke really eloquently about
the value of working in a team
as a way to learn and refocus
on relationship-centered care.
Eliza: Sometimes a really cool way to get
there is to also see a patient together.
I remember doing some outreach visits and
we had this phenomenal social worker with
us and we saw some patients together and
took a history together and I just learned
so much from the perspective of social
work that those few half days that we
spent together really stayed with me and
really informed the way that I approach a
history for our patient who is vulnerable
and how I work with them to identify
what their priorities are as opposed
to projecting my own list onto them.
So I think seeing patients together is
a really valuable way to collaborate.
Morgan: Of course at Team
Up we're on board here.
And totally biased when it comes
to team-based care, but we also
acknowledge that there are challenges
and layers of complexity with teams.
Eliza: We have such a high degree of
autonomy that sometimes you get caught
up into this approach to doing things,
and one example I could think of was
in one of the sites I've worked at, I
realized that I had a lot of shared care
with one of the counselors on the site.
And we are always trying to catch
each other and find each other
and give each other an update.
And, you know, someone would be, a patient
would be in crisis and someone else
would need a different type of support.
And we realized that what we needed
was 30 minutes together every week
scheduled with a list of our shared
clients with their consent so that
we could actually collaborate on what
they needed and prioritize and sort
of fill in the gaps for each other.
And that for me can be a really
effective way to connect with
other members of my team.
Sarah: I know you have a story you
often tell about this exact challenge
The challenge of, finding that time
to connect with a new team member.
Morgan: Yeah, I do, and, in multiple
iterations of work, when new people come
on, or I joined a new team over the years,
it's always tricky to find the time.
very early on I got to work with a
nurse practitioner, and I think it's
harder with nurse practitioners than
nurses or other providers when you're
not sharing a panel of patients.
if a nurse practitioner joins a practice
as a primary care provider, Sarah, they
will have their own panel of course.
And so you're not sharing patients
quite as much and when you're
working with a nurse, you're
more often to be sharing a panel.
Or they're sharing your panel
or however you wanna phrase it.
So I think that's the extra hard part
is that you're not naturally doing that.
So finding a way to do that sharing,
we have, done some of the training
and that's been a great way to
get to know nurse practitioners.
A really fortunate thing for
Kool-Aid in our clinic is that,
Several of our great nurses have
left to become nurse practitioners
and come back, and so we knew them.
And we know them in a new
role, and that's been so cool.
Sarah: What that highlights to me is you
really need that intentional process,
that intentional time to figure out, how
you're gonna work together, particularly
with the nurse practitioner role.
And I also think, you putting my
medical anthropologist hat on here
a bit, you know, when we think
about nurse practitioner role in
particular, there's a lot of power
dynamics and kind of traditional
hierarchies that come into the mix.
You the medical system, gender lines,
particularly traditional nurse doctor
relationships, and this is something that
Sydney reflected on as she talked about,
the evolution of her team over time.
Sydney: When we first came together
as a team, I think some members
of the team were used to working
traditionally, in a little bit more
of kind of a hierarchical setting.
And so, Adjusting to being on a team
where there really is no hierarchy.
we're all on equal footing, and we're all
trying to provide the same thing to the
patient, which is the best care possible.
And so I think there's always just
those growing pains as people adjust to
working on a team and realizing that,
you know, we are all in it together.
and I think when the scope of practice
overlaps, which it often does between
different care providers, there have
been some growing pains as we try
to sort out, well, whose job is it
going to be then pulling out the
details of who is going to do what and
when, sometimes can be a challenge.
But I think we've really, as a group,
worked through those processes and we
have great leadership that continues
to help devise standard work processes
that help determine when it's best
for the patients to have which kind
of care and that kind of thing.
I do think it's really important
because when everyone's doing what
they need to do, the patient care is
much smoother, more coordinated, and
ultimately better for the patient.
Morgan: So NPS absolutely
facilitate that coordinated patient
care as Sydney talked about.
Spence, U P C C RN calls out the
nurse practitioner's superpower.
Spence: I think they're
very good at being humble.
they always go out of their way
to help with an education point or
talking about something or explaining
something if you have a question.
So , it seems weird to say their humility,
but with that, I mean, their humility
mixed with their helpfulness, I think
that's their superpower and they're so
knowledgeable and, and well versed and
they're very, cautious and methodical
with how they approach patient care.
Sarah: And you know, this humility really
came across in all our conversations
as well, and as we've been doing all
season, we asked the nurse practitioners
we connected with for advice as to
what they would recommend folks should
do if an NP is joining their team.
Kelvin: like looking back on the
team, so it's not just you as a clinic
owner or you as a clinic, manager.
What is your team understanding
of a nurse practitioner role?
What do your MOAs think about that?
How is it different or the same?
Maybe you wanna put in places a
patient mapping of that experience
journey for your patients of what
it means so when you come in and
you're gonna be booked with an np.
so those are the things that you
wanna do that in the beginning,
throughout and those pauses, the
building the time to take the time.
to evaluate how are things going,
you know, what's not working well
or what are we celebrating together
or where we might need to be like
holding tension or naming tension.
And invite your MOAs and other
team members to an interview panel.
We wanna focus on that shared
equity, like the equity and the
power of decision making and to
add to that, it's about values.
it's about sharing, like what is
the values of our clinic, how do
we wanna actually work as a team?
I think the thing is, when you have
that upfront discussion too, it really
knows if you are, if you're gonna
fit, as a team and work together..
Morgan: That's Kelvin again, on
the importance of creating the
time to connect and communicate
and make sure that expectations
around working together are clear.
I like their integration guidebook
idea that's on their website, sarah.
I think that's very cool.
We have something similar, we call
it an onboarding manual, at the ISU.
only.
theirs is obviously a
more clinically focused.
Because it's online we'll put a link
in the show notes if people are curious.
Now we talk about getting to know
your team all the time, obviously,
and others who have learned to work
together know how important this is too.
So it's not just us, but
people like Sydney agree.
Sydney: I think step one, learn
about each team member's training
and scope and what picture they
have of their role in the clinic.
And then step two would be to kind of
standardize the roles as much as possible.
And then step three is just that
constant, evolution, you know,
evaluating where things are at and
being honest and open with each other
when there are challenges, and finding
a way to work through that together.
Sarah: Sydney went on in our
conversation to shift to a focus
on communication and how important
clear communication pathways and
opportunities for connection really are.
And this is nothing new.
We've said this before, but Eliza
also looped back to the same idea.
Eliza: I think it's important to set
up a good cadence for communication.
So, the weekly huddles, making sure
if it's a PCN P contract that they're
involved in setting up the practice
level agreement, plan how you're going
to cover each other when you're away.
Plan how you can ensure that if you're
not working, if your patient has an
urgent concern that schedules are blocked
off accordingly, so that there's same
day urgent bookings that are available.
And then just talking about how to really
strengthen the relationship and make
it as powerful as possible so that when
there are concerns or confusion down the
road, how do we connect with each other?
Do you wanna talk on the phone?
Do you want to talk by email?
Should we grab a coffee?
Would you like to get lunch?
Like really building that
relationship up before things
get busy on a practical level.
All of that's
Morgan: I love how she ties communication
and relationships across the team
together here in what she described.
Sarah: And Morgan, you know
what I'm realizing as we
progressed through this season.
We asked everyone what they would
recommend if Role X is joining their team.
When we went out and talked to over
30 providers, these recommendations
are very rarely role specific.
They're recommendations that help build
those high functioning teams in general.
Morgan: They absolutely are Sarah,
and that's why the recommendations
are always so similar.
I think that we're people first.
And then we are in our
provider role second.
So to wrap up this episode, what
are our calls to action for today?
Sarah: these are calls to action
if an NP is joining your team.
But really, like I said,
these are generalizable.
So firstly, it's that
create time to connect.
Morgan: And then I think second
would be building that shared
understanding of the roles and then
try to standardize wherever possible.
This is particularly true when
there's very real overlap.
And it also helps our patients understand.
Sarah: Yeah.
And that communication to patients piece
about role pieces, that's so critical.
Right?
and lastly, I think figure out
communication pathways and build
a good communication cadence to
support coordination and also
relationships across the team.
And then to go back to this idea
of the team as including patients.
So when we think about communication,
it's not just communication across
the providers, but also to the
patients and how that's happening.
Morgan: I totally agree, Sarah, and
I think that wraps up, our episode
on nurse practitioners this week.
Sarah: Thanks for listening, and as
always, we'd love to hear from you.
if you have any ideas about things
you'd like us to touch on in this
season or in the next season, send
us an email at isu@familymed.ubc.ca.