Nurses acting like physicians

[preppy038]

Why not just be a Male Nurse? We are severely lacking them.

 

i'd def hire a male nurse over a female nurse

[leviathan]

I don't really like getting into these discussions because it inevitably makes me seem hostile to RNs. I'm not. They play an immense, inextricable, and utterly central role in the health care system in pretty much every context, and they tend to have excellent judgement when it comes to triaging patients and, especially, knowing when something is wrong. We are a team and that's the way it will always be.

This x 100000. People invariably misinterpret our posts as being anti-nurse. I love nurses, I have lots of friends who are nurses, and we get along well. I just don't understand this new phenomenon of nurses who suddenly think they are equal to MDs with a fraction of the training. NPs are also safe, when they are working in the right environment. It seems with nurses that the more you give them the more they want, if you look at the CRNA problem in the states. That's what scares me. I have worked with both CRNAs and MD anesthesiologists and the differences are strikingly obvious when you get past the basics of induction and maintenance of anesthesia.

 

A related example occurred on my first clerkship block when my friend had to explain to the PICU nurse that hyperkalemia in DKA was the result of the acidosis and would be improved with insulin.

Bit of a digression but out of interest, the hyperkalemia in DKA is actually not from acidosis. According to Uptodate, it's actually from both the insulin deficiency and from osmotic effects. Organic acids enter the cell with sodium to maintain electroneutrality, as opposed to other forms of acidosis where the H+/K+ antiport system works and does lead to hyperkalemia.

 

I'm only mentioning this because I just recently learned it, as most people (including myself) are taught the other theory. Nevertheless, giving insulin is still part of the correct treatment for it. As we both know giving potassium is also treatment once the K is normalizing, which we have had to explain to nursing staff once on a med-surg ward before pt moved to ICU.

[futureGP]

Bit of a digression but out of interest, the hyperkalemia in DKA is actually not from acidosis. According to Uptodate, it's actually from both the insulin deficiency and from osmotic effects. Organic acids enter the cell with sodium to maintain electroneutrality, as opposed to other forms of acidosis where the H+/K+ antiport system works and does lead to hyperkalemia.

cool so then is it a direct effect of low insulin?

[leviathan]

cool so then is it a direct effect of low insulin?

That and hyperosmolality. There's a theory that when water leaves the cell from the hyperosmolality, potassium is dragged along with it passively via potassium channels. Acidosis isnt thought to be a part of DKA or lactic acidosis because of an organic acid transporter. Other types of metabolic acidosis do have the H+/K+ system involved though.

 

The theory is supported by the fact that hyperglycemic hyperosmolar state (HHS or 'HONK') still has hyperkalemia despite there being no acidosis.

 

This is all pretty much paraphrased from Uptodate btw, so you can look it up there.

[Robin Hood]

A bachelor may become obliatory for nurse practice in 2014 in Québec.

[concernedmedstudent]

This blog has finally died - but I came across a blatantly obvious example of the different level of thinking between physician thinking and nurse thinking.

 

When discussing Metabolic Alkalosis in the context of vomiting I overheard two different sets of teaching:

 

1.) Nurse teaching nursing students "When patients vomit they vomit HCL and thus become alkalotic due to vomiting out H+"

 

Physician teaching junior medical students: "Alkalosis in the setting of vomiting is dependent on several homeostatic mechanisms. First there is loss of acidic stomach content, but in a patient with a normal kidney this would be relatively well compensated for. Secondly along with vomiting comes volume depletion. Volume depletion will lead to activation of the RAS system as well as ADH via decreased effective circulating volume. This will result in an increase of aldosterone at the level of the kidney and therefore increase the excretion of H+(and K+) in order to reabsorb Na at the DCT in an effort to maintain ECV. Thus there will be increased loss of H+(which is equivalent to gaining HCO3-) at the level of the kidney - thus contributing to the metabolic alkalosis.

 

See the difference of understanding? Also how this would make a difference in the treatment? Both groups will claim to have an understanding of metabolic alkalosis in the context of vomiting but only one group really understands the WHY.

[widedentist]

In this thread - insecure med students puffing their chests

[ems4everlife]

In this thread - insecure med students puffing their chests

 

+1000

 

Just because someone is a nurse, doesn't mean that they don't have previous education.

 

PS I would love to see a med student give a full detailed answer as such.

[hexonu]

This blog has finally died - but I came across a blatantly obvious example of the different level of thinking between physician thinking and nurse thinking.

 

When discussing Metabolic Alkalosis in the context of vomiting I overheard two different sets of teaching:

 

1.) Nurse teaching nursing students "When patients vomit they vomit HCL and thus become alkalotic due to vomiting out H+"

 

Physician teaching junior medical students: "Alkalosis in the setting of vomiting is dependent on several homeostatic mechanisms. First there is loss of acidic stomach content, but in a patient with a normal kidney this would be relatively well compensated for. Secondly along with vomiting comes volume depletion. Volume depletion will lead to activation of the RAS system as well as ADH via decreased effective circulating volume. This will result in an increase of aldosterone at the level of the kidney and therefore increase the excretion of H+(and K+) in order to reabsorb Na at the DCT in an effort to maintain ECV. Thus there will be increased loss of H+(which is equivalent to gaining HCO3-) at the level of the kidney - thus contributing to the metabolic alkalosis.

 

See the difference of understanding? Also how this would make a difference in the treatment? Both groups will claim to have an understanding of metabolic alkalosis in the context of vomiting but only one group really understands the WHY.

 

No one here is talking about nursing student we're talking about Nurse practioners who have a plethora of experience and take advanced patho classes. I'm not even sure why this is still being debated as NPs already have prescribing powers and its been highly successfully so far.

Nursing organization is very powerful and over the years we'll see more of them moving into primary care.

[kpm]

Even to be eligible to apply to 2-year RN degrees, you need to take Anatomy and Physiology. In my A&P course, we learned the detailed explanation of metabolic/respiratory alkalosis/acidosis. I haven't even started 1st year, and I understand the long explanation, therefore I understand the WHY.

 

Also, just because you overheard one nurse giving a bad explanation and one physician giving an excellent explanation doesn't mean you can generalize that to all nurses and all physicians.

[hexonu]

Even to be eligible to apply to 2-year RN degrees, you need to take Anatomy and Physiology. In my A&P course, we learned the detailed explanation of metabolic/respiratory alkalosis/acidosis. I haven't even started 1st year, and I understand the long explanation, therefore I understand the WHY.

 

Also, just because you overheard one nurse giving a bad explanation and one physician giving an excellent explanation doesn't mean you can generalize that to all nurses and all physicians.

 

Agreed. The information concernedmedstudent is claiming is beyond RN comprehension - I learned in first year physiology as part of my BscN. This thread is just for med students to gas themselves up.

[concernedmedstudent]

I'm not saying that nurses can't or don't understand the more detailed explanation I'm merely suggesting that the level of detail that is taught in medical school vs nursing school is very different. Why? because the two careers are very different. Different being the key word, not better or worse. As a patient I don't really care whether or not my nurse understands the details of my medical condition for the same reason that I wouldn't really care if my Internal Medicine specialist was any good at obtaining peripheral IV access or able to adjust my IV drip rate. I do however hope that my nurse is proficient at inserting my IV and setting the drip to whatever my internal medicine physician has ordered for me. It takes an entire TEAM to manage a patient. Everyone is important from the sub sub specialist to the housekeeping staff, a hospital requires many people with multiple areas of expertise to run.

 

It is just frustrating when people try to equate apples and oranges. I would imagine that RNs would get frustrated if LPNs claimed to have the same knowledge and training and LPNs would be upset if care aids claimed that they were the same.

 

Like it or not there is a hierarchy in hospitals but every level of the pyramid is IMPORTANT and must work together!!! A strong Base is CRUCIAL!

[A-Stark]

Agreed. The information concernedmedstudent is claiming is beyond RN comprehension - I learned in first year physiology as part of my BscN. This thread is just for med students to gas themselves up.

 

Uh huh. I don't think so.

 

To take another example, I've worked with experienced wound care nurses who don't know much about the micro or antimicrobials you'd think was directly relevant to what they do.

 

In any case, the major difference between medical school and any regular undergrad degree is the volume of material and the speed at which it's delivered. We probably don't learn nearly enough physiology or pathology even so.

[hexonu]

As a patient I don't really care whether or not my nurse understands the details of my medical condition for the same reason that I wouldn't really care if my Internal Medicine specialist was any good at obtaining peripheral IV access or able to adjust my IV drip rate.

 

 

Okay, starting tommorow we'll tell all the oncology nurses to forgot everything they've ever learned about cancer and we'll see how well that works? It's an RNs job to know about your medical condition how else will they take care of you if they don't know anything about your condition.

 

Uh huh. I don't think so.

 

To take another example, I've worked with experienced wound care nurses who don't know much about the micro or antimicrobials you'd think was directly relevant to what they do.

 

In any case, the major difference between medical school and any regular undergrad degree is the volume of material and the speed at which it's delivered. We probably don't learn nearly enough physiology or pathology even so.

 

The deficiency is knowledge is probably because they were diploma nurses who were grandfathered into the system after BScN/BN became entry to practice. I'm certain that every BScN program in Canada has at least one full semester of medical microbiology.

 

For the record I'm not saying nurses and physicians are on par in terms of education but a lot of people in this thread are under belief that nurses use no critical thinking skills. We're there to make sure physicians don't kill patients. I always tell other nurses when they carry out an order to make sure they know exactly what they are doing. After all, our license is on the line too.

[rswim]

It is always nice to get physicians who started as nurses to comment on the matter - they bring a very unique perspective.

 

I have chatted with a few and they very much changed their opinion on both professions after having gone through both.

 

One issue is that physicians don't know much about nursing and what it takes to be a great nurse. To their credit though they don't pretend to know as much about nursing as nurses. On the contrary there are quite a few nurses that seem to think they know a lot about how to be a physician. I think that is were some of the tension comes from. The vast majority however are secure enough and recognize that they are two separate fields each with unique skills and abilities.

 

Unless you've been in both careers you simply will not understand the vast differences in training. I certainly don't know the details of what nursing programs entails.

[medisforme]

 

The deficiency is knowledge is probably because they were diploma nurses who were grandfathered into the system after BScN/BN became entry to practice. I'm certain that every BScN program in Canada has at least one full semester of medical microbiology.

 

My BScN degree did not have any medical microbiology - graduated 2005.

I just finished my first year of medical school and have definitely formed an appreciation for how distinct the two professions are - I am sure this will be amplified once I enter clerkship.

[A-Stark]

The deficiency is knowledge is probably because they were diploma nurses who were grandfathered into the system after BScN/BN became entry to practice. I'm certain that every BScN program in Canada has at least one full semester of medical microbiology.

 

So a wound care nurse with 25 years experience is going to know less about this stuff than a new grad who may or may have not been required to take a half course in micro? Seems rather presumptuous. I learned a lot about the "art" of wound care working with this RN.

 

For the record I'm not saying nurses and physicians are on par in terms of education but a lot of people in this thread are under belief that nurses use no critical thinking skills. We're there to make sure physicians don't kill patients. I always tell other nurses when they carry out an order to make sure they know exactly what they are doing. After all, our license is on the line too.

 

I think this kind of defensiveness grossly overstates our comments here. It's not about critical thinking skills at all, but medical decision making. RNs frequently have superb intuition about how a patient is doing, but that doesn't mean they know how to manage a lot of things, and often there is more algorithmic thinking going on or calls for excessive consults when they don't feel comfortable. To be fair, physicians make inappropriate consults too and some make poor decisions.

 

But to suggest that nurses are around to "make sure physicians don't kill patients" is an appalling mentality. We are not at odds with each other, and the system only works through continual feedback and teamwork.

 

(Though for the record I am pretty comfortable with IVs, fiddling with monitors, etc.)

[widedentist]

Physicians make way more money and have way more prestige. Nurses are just the poop clean up crew. And we get laid off first too

[medisforme]

We're there to make sure physicians don't kill patients. I always tell other nurses when they carry out an order to make sure they know exactly what they are doing. After all, our license is on the line too.

 

This is a ridiculous comment that goes completely against the health care team philosophy that we are all supposed to be using when providing patient care.

Furthermore, in 8 years working as an RN, the vast majority of cases where patient treatment/care has been compromised in some way, it is often due to poor nursing care, laziness, not reading orders etc... (I honestly believe many people [though a very small minority overall] go into nursing without a full understanding of what it entails, and end up making relatively poor nurses).

 

Also, just for the record, having been a BCNU steward for 4 years, due to our ridiculously strong union, it is virtually impossible to lose your license/job unless you engage in malevolent, gross negligence (ie. I know of a case where a nurse "misread" an insulin order and gave 10ml instead of 10 units, patient died. - after a short re-education course- they were allowed to go back to their regular line).

[aaronjw]

This is a ridiculous comment that goes completely against the health care team philosophy that we are all supposed to be using when providing patient care.

Furthermore, in 8 years working as an RN, the vast majority of cases where patient treatment/care has been compromised in some way, it is often due to poor nursing care, laziness, not reading orders etc... (I honestly believe many people [though a very small minority overall] go into nursing without a full understanding of what it entails, and end up making relatively poor nurses).

 

Also, just for the record, having been a BCNU steward for 4 years, due to our ridiculously strong union, it is virtually impossible to lose your license/job unless you engage in malevolent, gross negligence (ie. I know of a case where a nurse "misread" an insulin order and gave 10ml instead of 10 units, patient died. - after a short re-education course- they were allowed to go back to their regular line).

 

10ml of insulin??????????????????

[A-Stark]

To stir the pot further, I was told the other day by some gyne floor nurses that they're not "allowed" to put NGs in patients who are obstructed... which they did after we pointed out that bowel obstruction is one of the main indications for an NG.

 

(The patient subsequently went to the OR for lysis of adhesions and relief of the SBO, and did well. Not that I regret being up all night managing her, but the next time someone says nurses "make sure physicians don't kill patients" I will use this example.)

[hexonu]

To stir the pot further, I was told the other day by some gyne floor nurses that they're not "allowed" to put NGs in patients who are obstructed... which they did after we pointed out that bowel obstruction is one of the main indications for an NG.

 

(The patient subsequently went to the OR for lysis of adhesions and relief of the SBO, and did well. Not that I regret being up all night managing her, but the next time someone says nurses "make sure physicians don't kill patients" I will use this example.)

 

I'm going to assume this post is directed at me since I made that statement. Did the nurses know you were ordering an NG for a SBO or a complete bowel obstruction? As the latter option they would be following hospital policy. I'm guessing they were new grads, a seasoned nurse would know an NG is used to remove excess gas/air from the bowels.

[A-Stark]

Yes, you made that comment.

 

They knew exactly why I was ordering an NG because I'd been on the floor with the patient for a while already. They weren't even remotely new grads either.

 

What, incidentally, differentiates an SBO from a "complete" bowel obstruction? The amount of feculent emesis? Floor nurses frequently quote various arbitrary "policies" but rarely produce them in writing. It's not like I was asking them to start an amiodarone infusion on the floor.

 

My point, if I have one, is that your earlier comment was so completely ridiculous that it was actually offensive to me and, I'm sure, many others. It demonstrates a very poor attitude, though perhaps you intended less serious than it came across. I would not fault any RNs for not feeling comfortable actively managing a sick patient on the floor - that's my job - and in this case they still fully recognized that she was indeed quite sick. They were also very attentive and made sure that I saw even the vomit. But good nursing care is not good medical care and setting up some kind of opposition is inappropriate, as is suggesting that nursing training (or NP training) is adequate preparation for any part of the job of a physician.

[widedentist]

There are many arbitrary policies... So many that it makes it difficult to the job

 

 

Yes, you made that comment.

 

They knew exactly why I was ordering an NG because I'd been on the floor with the patient for a while already. They weren't even remotely new grads either.

 

What, incidentally, differentiates an SBO from a "complete" bowel obstruction? The amount of feculent emesis? Floor nurses frequently quote various arbitrary "policies" but rarely produce them in writing. It's not like I was asking them to start an amiodarone infusion on the floor.

 

My point, if I have one, is that your earlier comment was so completely ridiculous that it was actually offensive to me and, I'm sure, many others. It demonstrates a very poor attitude, though perhaps you intended less serious than it came across. I would not fault any RNs for not feeling comfortable actively managing a sick patient on the floor - that's my job - and in this case they still fully recognized that she was indeed quite sick. They were also very attentive and made sure that I saw even the vomit. But good nursing care is not good medical care and setting up some kind of opposition is inappropriate, as is suggesting that nursing training (or NP training) is adequate preparation for any part of the job of a physician.

[hexonu]

Yes, you made that comment.

 

They knew exactly why I was ordering an NG because I'd been on the floor with the patient for a while already. They weren't even remotely new grads either.

 

What, incidentally, differentiates an SBO from a "complete" bowel obstruction? The amount of feculent emesis? Floor nurses frequently quote various arbitrary "policies" but rarely produce them in writing. It's not like I was asking them to start an amiodarone infusion on the floor.

 

My point, if I have one, is that your earlier comment was so completely ridiculous that it was actually offensive to me and, I'm sure, many others. It demonstrates a very poor attitude, though perhaps you intended less serious than it came across. I would not fault any RNs for not feeling comfortable actively managing a sick patient on the floor - that's my job - and in this case they still fully recognized that she was indeed quite sick. They were also very attentive and made sure that I saw even the vomit. But good nursing care is not good medical care and setting up some kind of opposition is inappropriate, as is suggesting that nursing training (or NP training) is adequate preparation for any part of the job of a physician.

 

 

This whole thread has been derailed to the point where we aren't even talking about the same thing anymore. The article in question discusses prescription rights for other healthcare providers other than physicians.

 

If we want to throw anecdotes in the mix then let's talk about a night shift were the resident kept writing the wrong orders, ex. IV when he meant PO. Not entirely sure what his deal was but the aftermath of these orders could have been potentially been fatal. Every time the nurses at triage would probe him for rationales he would say "you know what I mean". So yes, the role of a nurse is to protect patients from inept physicians, which do exist whether or not you would like to admit. It really goes both ways. One of the primary tenants of nursing is patient advocacy, so I stand by my statement.

 

 

as is suggesting that nursing training (or NP training) is adequate preparation for any part of the job of a physician.

 

I'm sure you made that comment of out self interest which is completely logical as you fear encroachment, but it's simply false. Nurse practitioners have been taking over GP role all over Ontario and Alberta (from what I know), and surprise! It's working. Also, NPs are taught to practice under a biopsychosocial model rather than a strictly medical model, so they shouldn't really be compared at all.

 

Anyways, it seems like this could go on forever so I suppose we should just agree to disagree. Oh and if you have an issue with "arbitrary policies" then perhaps you should go into policy making. As much as we nurses despise them, they are policies we have no control over so it seems silly to fault us for them.