0:00

Sarah: Are you curious about how primary care nurses can help

0:02

patients with mental health needs? Yeah, me too.

0:38

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

0:41

concerns, mood disorders specifically.

0:44

Why highlight this one? Morgan TLM103 MixPre: lots of reasons, Sarah.

0:46

I think first, it's common. I recently read a paper that anxiety was the number one reason

0:51

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

0:55

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

0:58

definitely support in primary care. I think it highlights something that nurses, a lot of nurses are

1:03

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

1:07

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

1:11

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

1:15

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

1:18

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

1:23

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

1:28

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

1:33

you know, pull teams together around. And I think nurses have those skills when you think about the coordination that's

1:38

needed around mental health supports.

1:41

Morgan TLM103 MixPre: Absolutely, they absolutely do. And there's actually more nurses in mental health than

1:45

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

1:51

the mental health care in primary care.

1:54

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

1:57

nurses as well, or RPNs. but those nurses really work right now, at least, in mental health

2:02

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

2:09

Morgan TLM103 MixPre: Yeah, and that's true, Sarah. I think there's a few reasons for why we haven't seen so many nurses in

2:14

sort of, primary care mental health. I think mental health in Canada, it's been more multidisciplinary

2:20

historically with more defined roles for nurses like case management.

2:24

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

2:28

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

2:34

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

2:38

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

2:43

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

2:48

lots of other primary care as well. So maybe it doesn't get highlighted as much.

2:52

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

2:55

to support people with mood disorders.

2:58

For thinking about supporting a patient kind of with stable

3:01

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

3:05

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

3:08

mild or, stable mental health issues.

3:11

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

3:16

stable and predictable patients. Angela: They're diploma prepared nurses.

3:19

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

3:24

but to folks who have stable and predictable health trajectories.

3:29

Sarah: That was Angela Wignall from NNPBC.

3:32

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

3:37

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

3:39

approach to assessing people with mental health concerns.

3:42

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

3:46

more on medical conditions. Even though she said she was less comfortable with mental health, her

3:51

approach is pretty comprehensive. Kacey: They would sit down with the patient and they would have a

3:55

conversation and they would assess them. So they would ask questions about their mood and about

4:01

what's going on in their life. Has this happened before?

4:04

How have you coped with it in the past?

4:06

Did it work? Did it not work? So a lot of that almost not motivational interviewing, but just finding

4:13

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

4:18

need to happen now or can it wait?

4:21

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

4:23

reassuring for how to assess and support somebody with depression.

4:27

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

4:31

Going back to what Angela said. An LPN is focused on stable patients.

4:36

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

4:42

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

4:46

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

4:50

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

4:54

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

4:58

that's why you would always hire an RN. But, but remember that we're all health professionals and we know

5:03

how to work within our scope. We know what our competencies are.

5:07

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

5:12

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

5:15

So they could consult the physician. Or the nurse practitioner down the hallway, or an RN on the team, and

5:21

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

5:25

then bring the team around that person. Sarah: Of course, that totally makes sense, and I think, you know,

5:29

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

5:33

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

5:36

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

5:39

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

5:43

mental health work in our practice. and there are several things that Hannah does all the time with

5:48

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

5:51

Cool. Here's Hannah. Hannah: the mental status exam can really highlight for a nurse who's

5:56

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

6:00

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

6:04

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

6:09

are great at getting collateral and historical information.

6:12

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

6:16

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

6:22

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

6:26

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

6:29

information as part of the team. Hannah mentioned assessing who is really acute at particular times.

6:35

And this kind of leads me to my next question.

6:38

Who triages more acute mental health issues in primary care?

6:42

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

6:47

if someone is in that space? Morgan TLM103 MixPre: Yeah, it depends.

6:50

I think RNs and registered psychiatric nurses, they triage.

6:54

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

6:58

practitioners and family doctors. So if it works in your team, registered nurses are well

7:03

positioned to triage in primary care.

7:06

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

7:11

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

7:16

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

7:22

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

7:27

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

7:33

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

7:37

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

7:43

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

7:48

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

7:52

some people would be willing to share.

7:55

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

7:57

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

8:01

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

8:04

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

8:10

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

8:15

need a medication, then what happens? Morgan TLM103 MixPre: Well, like with all of us, we need to have

8:19

appropriate escalation pathways. Here's Angela from NNPBC on that.

8:24

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

8:29

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

8:32

We usually will create for ourselves referral processes

8:36

for what that looks like. So in the context of a primary care clinic, it might be as simple as, popping

8:42

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

8:47

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

8:51

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

8:54

teams to support our patients as well. Angela: It may also include external escalation.

8:59

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

9:03

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

9:07

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

9:14

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

9:19

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

9:22

Sarah: That sounds kind of stressful. It's, not something that I deal with every day, that's for sure.

9:25

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

9:28

primary care deal with every day as well. Sarah: Well, and I think that kind of leads well into my

9:33

next area of kind of questions. Let's, talk a little bit more about support and debriefing

9:38

when things do get, escalated. hearing about your practice, Morgan, and all the stress people are under,

9:43

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

9:47

high levels of anxiety in primary care.

9:50

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

9:55

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

9:58

other, at least the way I think about it. The first one is in the moment, during that intense encounter, that And

10:05

that's one way that teams really shine. I think at Kool Aid we do this all the time.

10:10

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

10:13

talking in the moment, debriefing.

10:15

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

10:19

Hannah: I think of an example of us at the supportive housing building

10:22

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

10:24

our patient didn't want to move. So he was so unwell, we just kept him there.

10:29

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

10:33

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

10:39

delusions, and we really worked as a team

10:42

Morgan TLM103 MixPre: So we were supporting our patient while supporting each other in the moment.

10:45

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

10:51

the other person stayed with the patient. Sarah: And I imagine that would have been really hard, if not

10:55

impossible, to do if you'd been alone.

10:58

Morgan TLM103 MixPre: Yeah, I think if I was alone, Sarah, I would have just had to call for help because we were both there, we could help our patient.

11:04

And they didn't have to go to hospital. Sarah: What's the other way that you support each other?

11:09

Morgan TLM103 MixPre: The other way is, after. So debriefing after a stressful event, as a team lead.

11:14

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

11:18

witnessing somebody in a dire situation.

11:21

Morgan TLM103 MixPre: That's Angela again. Angela: They're very real. We carry them with us.

11:24

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

11:29

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

11:32

We have that person in our mind immediately.

11:35

So we carry those we care for with us.

11:37

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

11:41

really important part of healing. Sarah: I know we've talked about how a team creates this structural resilience,

11:46

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

11:50

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

11:54

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

11:58

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

12:02

and supporting provider wellness. We know right now that, you know, providers are, very strained, so anything

12:08

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

12:13

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

12:17

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

12:19

a mental health crisis, obviously. I mean, that's what we're talking about here.

12:23

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

12:27

throughout your day in primary care. anything that either of you are holding on to, that you need to

12:32

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

12:34

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

12:39

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

12:43

Morgan TLM103 MixPre: Absolutely. Yeah. Sarah: Okay, Morgan, so this has been, you know, a really wide

12:46

ranging and, interesting discussion. What's a key takeaway for our audience today?

12:51

Morgan TLM103 MixPre: I think just talking about the mental health escalation procedure for each of you, that's an important first step, even

12:58

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

13:01

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

13:05

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

13:09

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

13:12

you need support in the moment too. It's not a, one way thing.

13:15

Morgan TLM103 MixPre: A hundred percent, Sarah. so I think, when working as a team compared to when I did solo

13:19

care, that's what I really missed. And Sarah, for you, what stood out?

13:24

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

13:27

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

13:32

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

13:36

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

13:41

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

13:45

Morgan TLM103 MixPre: Well, Sarah, that sounds like a good place to wrap up this episode.

13:48

Sarah: It does. See you next time. Morgan TLM103 MixPre: Thanks for listening to Team Up, and if you have

13:52

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

13:56

ubc. ca. Sarah: The Innovation Support Unit is a distributed multidisciplinary team.

14:03

We work mostly remotely from communities across the Lower Mainland and

14:07

Vancouver Island in British Columbia. Morgan: Sarah and I are both recording from our offices in the territories

14:13

of the Lekwungen speaking peoples, the Songhees and Esquimalt First Nations.

14:17

Sarah: And recognizing the colonial history and the ongoing impacts of

14:21

colonization and healthcare systems and in Indigenous communities in

14:24

Canada and around the world, as we move through the season, we'll work

14:27

to bring an equity lens to this work. And we really encourage you, our listener, to reflect on your past,

14:33

present, and future participation. On the indigenous lands where you are situated.