From Novice to Expert: The Journey A Vision for the Patient’s Health Home and Team Based Care

From Novice to Expert: The JourneyA Vision for the Patient’s Health Home and Team Based Care Presented to: CFPNA September 27, 2014 Presented by: Treena Klassen PalliserPCN Executive Director

What does dialectics mean??? Logical and reasoned argument to arrive at “truth” (Socrates, a long time ago).

Agenda • Treena Klassen RN, BN, ASMH, MEd • Palliser PCN • Concepts of: • Novice to expert journey • Health Home • RNs and Team Based Care / Collaborative Family Practice • Family Practice Success Stories • Family Practice Challenges • Support through Public Reflection • Lifelong Learning in Family Practice

Palliser PCN - Background Received approval of its initial Business Plan in August 2006. VISION: Our commitment is to work collaboratively to develop and implement primary care delivery models aimed at improving access, quality of care and satisfaction for both patient and health care providers. During this time over 93% of local Family Physicians have joined the PCN and the vast majority of these physicians have an RN working with them in their clinics.

PCN Geographical Region Crescent Heights Family Medical Clinic Carry Drive Clinic Oyen Medical Clinic Dr. Augustine Dr. Correia Dr. Duke Dr. Durand Dr. Harrison Dr. Keshvara Bassano Medical Clinic Dr. Mastel Dr. Prince Dr. F. Rinaldi Dr. Saujani Brooks Medical Clinic Dr. Viljoen Newell Medical Clinic Dr. Wong Health Matters Medical Clinic Centennial Medical Clinic HealthWorx Medical Clinic South Shore Medical Clinic Meiring & Kriel Family Practice Primacy Medical Clinic (Dr. Filanti) Brooks Hospital: - Family Medical Maternity Clinic - Immigrant Clinic Riverside Medical Clinc Sage Family Clinic Southlands Medical Clinic Bow Island Medical Clinic The Avenues (Dr. Thorogood) The Ridge (Dr. Mohanraj) MHRH: - Family Medical Maternity Clinic Foremost Medical Clinic

Novice to Expert Differences between the experienced nurse and the novice Takes into account increments in skill performance based on experience as well as education. Lets apply this model to primary care and then utilize this framework for assessing how to best help ourselves and each other to become effective team members in the Health Home.

Lets define family practice care skills Acute Family Practice Often work without other nurses around Often the “task” is unclear Often have to seek work (patients may be used to only coming to see the doctor) Often have very limited policy and procedure to follow • Typically work amongst nursing colleagues • Typically have an identified task to complete • Work comes to you (patients are admitted to your unit) • Typically have substantial amounts of policy / procedure to follow

Level I: Novice • No experience with the situations • Rules to guide action in respect to different attributes • Inability to use discretionary judgment • Context-free rules to guide task performance

Level II: Advanced Beginner • Able to note (or have pointed out by a mentor) recurrent meaningful situational components (aspects). • Aspect recognition is dependent on prior experience in actual situations. • Can formulate guidelines on aspects, however all aspects are considered equally important. • Not able to take in information from context as must focus on remembering the rules. • These nurses need help in setting priorities and benefit from being backed up by a competent level nurse to ensure that important patient needs do not go unattended.

Level III: Competent • Typified by the nurse who has been on the job two to three years. • The nurse begins to see his or her actions in terms of long-range goals or plans. • The nurse is consciously aware of these plans, and the goal or plan dictates which attributes and aspects of the current and contemplated future situation are to be considered most important and which can be ignored.

Level IV: Proficient • Nurse perceives situations as wholes, rather than in terms of aspects and performance is guided by maxims. • Experience teaches the proficient nurse what typical events to expect in a given situation and how to modify plans in response to these events. • Nurse can recognize when the expected normal picture does not present itself --- thus improving his/her decision making. • Nurse has a deep understanding of situation so can determine which maxims to apply.

Level V: Expert • Enormous background of experience. • Has an intuitive grasp of the situation. • Zeros in on the accurate region of the problem without wasteful consideration of a large range of unfruitful possible problem situations. • Has a vision of what is possible. • Is able to offer ways of understanding and avenues of acceptance. • Through the nurses own ability to face and cope with the problem, the patient can come to sense that the problem is approachable and manageable.

Agenda • Treena Klassen RN, BN, ASMH, MEd • Palliser PCN • Concepts of: • Novice to expert journey • Health Home • RNs and Collaborative Family Practice • Family Practice Success Stories • Family Practice Challenges • Support through Public Reflection • Lifelong Learning in Family Practice

The Medical Home Described by the College of Family Physicians of Canada as: “The home base for the continuous interaction between patients and their personal family physicians, who are the most responsible providers (MRPs) of their medical care. It is where a team or network of caregivers, including nurses, physician assistants, and other health professionals – located in the same physical site or linked virtually from different practice sites throughout the local or extended community – work together with the patient’s personal family physician to provide and coordinate a comprehensive range of medical and health care services required by each person”.

RNs in Collaborative Family Practice Discrepancies among professional organizations, front-line RNs, leaders and health policy decision-makers related to the theory and the reality in primary care, with the identity of RNs needing to be enhanced (Kennedy, 2014)

What is the RN role in Family Practice?

Well baby checks and immunizations (certification) Cervical smears (certification). Wound care Dx. Tests such as spirometry Assisting with minor surgical procedures Giving injections Providing adult immunizations Triaging Administering nebulizers Suture/staple removal Counselling General health screening Mental health screening Patient education Health promotion Enabling patients to improve their own health and well-being Managing continuous quality improvement Managing recall registries/EMR standardization Assessing social determinants of health Prevent and close gaps in care Case Management and care coordination Nursing in primary care

Explicit Palliser PCN RN Role Priority is comprehensive and complex care focusing on the following services: Disease Management: Diabetes, hypertension & other cardiovascular disease (CHF, atrial fibrillation, peripheral artery disease), blood pressure management, dyslipidemia, obesity, COPD/asthma, chronic digestive disorders (celiac disease), chronic pain (non cancer pain), and osteoporosis Complex Care: Those with co-morbidities, ill defined illness, complex socio-economic status Disease Screening: Metabolic syndrome, dyslipidemia, diabetes, kidney disease, anemia, thyroid, dementia, depression, alcohol use, hearing and vision investigation

Explict Objectives (2) Disease Prevention: Education on smoking cessation, immunization, healthy nutrition and exercise. Health Maintenance: Socioeconomic issues as they pertain to medication and health aids, palliative and end of life care.

Family Practice Nurse Art: Implicit RN Objectives • Sell the nursing service • Office practice improvement • Share their knowledge with their colleagues • Support each other through positivity

Family Practice Success Stories

Some Physician Stories • The PCN has been a boom to my practice! It allows a much greater quality of service & allows in house provision & coordination for much of their chronic disease management • Patients are better educated • Patients want to see the nurse instead of me • The nurse knows more about diabetes then I ever will • I would have to retire if I didn't have PCN help • I couldn’t have opened my panel without the nurse • If government funding went away I would definitely pay for the nurse out of my pocket …. She makes my life better

Some Patient Stories • Most of the time there is very little wait time for appointments -, most of all I appreciate the follow-up • Excellent care - very professional • Very pleased with the care, results are important but how they are relayed with suggestions from the nurse makes a big difference as it helps to motivate • Love the time she spends explaining and makes me feel very much at ease about things involving my health • I have received excellent care and can see the doctor quicker if I have a problem • Having a PCN Registered Nurse is one of the best ideas healthcare has come up with. It has helped me a lot. • I would not have improved my health if it were not for her suggestions and willingness to problem solve • Excellent care & knowledge

Family Practice Challenges

How can management help? • Education • Public reflection • Change management • Scope definition

How can you help? (Transformative Learning) • Critical reflection of self-behavior • Identification of values or assumptions underlying the behavior • Changes in underlying values or assumptions • Change in the behavior. • (Heorhiadi et al., 2014)

What one “skill” is imperative in Family Practice Nursing? • Critical Thinking. • Knowledge acquisition alone is insufficient for practitioners to function in complex clinical environments (Papp et al., 2014).

Homework What is one thing you can do next week to increase the profile of nurses in team based care and/or in supporting the development of the Health Home?

Next Steps • As a group: • Improved research in primary care, particularly in the areas of specific provider characteristics and process of working together. • Ensure you have a voice at the political, educational and planning tables (CFPNA) • As individuals: • Lifelong learning in Family Practice Nursing • Ensure the public knows what you do. Always be a role model for your profession.

Conclusion

From Novice to Expert: The Journey A Vision for the Patient’s Health Home and Team Based Care