Diagnosis By Nurses

[masterb]

Thoughts and comments? What does this mean for primary care specialties e.g. Emergency Medicine, Family Medicine and future turf of other areas...

 

http://www.cbc.ca/metromorning/episodes/2013/04/15/diagnosis-by-nurses/

[Diceroll2011]

Nurses know everything

[Orcamute]

More donut time?

[Diceroll2011]

coffee break

[bones]

Don't know the details of how exactly nurses want to expand their scope in this case, but some thoughts:

 

-Training in differential diagnosis?

-Training in evidence-based medicine/critical thinking?

-Clinical acumen to recognize red flags?

-Medico-legal responsibility?

-Who will do nursing responsibilities?

-Funding model?

 

This topic seems to come up again and again in different parts of the country. What is the long-term vision of health care implicit in this push for greater scope? What do the Nursing associations want Canadian health care to look like?

 

Another troubling thought in my mind: it sounds like they want to create nurses that are similar to poorly trained and/or lazy and/or overworked physicians (i.e. physicians who do not take the time to consider DDx, who refuse to keep up to date with current scientific knowledge, etc.). Is this what we want/need?

[RiceWine]

Nurses know everything

 

when pathology becomes part of the curriculum

[NLengr]

Are nurses safe to consider differential diagnoses?

 

NP's maybe depending on the circumstances. RN's, absolutely not, unless training is completely revamped. I like the RN's that I work with but there is no way I believe they are capable of performing assessments, interpreting results and recommending treatments like a physician, or even NP, would be able to. The thought of it actually worries me for my patients safety.

[Lunasly]

NP's maybe depending on the circumstances. RN's, absolutely not, unless training is completely revamped. I like the RN's that I work with but there is no way I believe they are capable of performing assessments, interpreting results and recommending treatments like a physician, or even NP, would be able to. The thought of it actually worries me for my patients safety.

 

Correct me if I'm wrong, but this argument is the entire basis for why U.S. physicians don't want nurses to take on a larger role in the health care system?

[A-Stark]

Nurses already play a very "large" role in the health care system, but to suggest that they should be expanding their "scope" into areas for which they lack both the experience and training is beyond the pale.

[laladeedee]

Nurses already play a very "large" role in the health care system, but to suggest that they should be expanding their "scope" into areas for which they lack both the experience and training is beyond the pale.

 

Im a nursing student, and I'm positive that if the role of nurses really does expand do give medical diagnosis/prescriptions they would definitely get the training for it, if not they would probably just accidentally kill people lol. I can barely even make a nursing diagnosis, let alone a medical one!?! the College of Nurses sets the competencies that nursing students must achieve before they graduate, and we must fulfill those competencies every semester. So, if these 2 things do get implemented it would also become apart of the competencies, and also be tested on the CRNE. But I've been hearing about the whole role expanding thing for a while but I guess nothing is really official yet. But: if nurses have to make diagnoses, prescribe/give meds, clean up poop, and be a waitress for some patients.. i can't imagine how busy the job will get.

[JacquiDent]

I am an RN, and feel that if this ever got pushed through there would have to be major revamps to the curriculum and current job description. They'd have to severely rebalance the current workload. However, in BC at least, there is currently a BIG push for LPNs to have a larger scope of practice (taking over all IV medications, for example). My thoughts are that if the LPN scope/education is expanding and changing at this rate, the RN's role is going to change as well to reflect that.

Currently I don't believe many nurses are competent to perform diagnosis. However, I work on a specialized unit and yes, there are some amazing nurses who regularly make better calls on decisions than patient's GPs outside the hospital do. We require post-degree training to work on our unit, and many RNs on different units also require this (ICU, PARR, Cardiac, to name a few). On a unit-specific basis, we are often more knowledgable in our fields than many of the GPs who do not routinely see patient's in these areas or levels of acuity. Yet we could never go out into the community and do the GPs job. And RN's from unspecialized units I don't think are often anywhere near the level of making diagnoses. It's a matter of specialization and further education between RNs at this point, and if diagnosis gets brought in there would have to be big changes within the BScN program to reflect that. Not just post-degree training. Over the last 10 years there have been huge changes to the RN and LPN programs, and I wouldn't be surprised to see this scope of practice continue to expand and the education change further.

There's talk of pharmacists getting rights to diagnose too eventually, but that's another topic

Just my 2 cents.

[masterb]

The interviewee in the link I posted mentioned RNs in nursing homes prescribing antibiotics for UTI, not really sure if a nursing home is as specialized in acute complex care such as ICU and if nursing home RNs get additional training in making primary care diagnosis. I can imagine - or my hypothesis is that - said RNs messing up when prescribing ABX's to nursing home residents with comorbidities including renal failure (talk about ABX toxicity, further frying their kidneys etc...) and to make things worse nursing homes don't have the kind of pharmacy coverage that acute care units have so there is no additional level of pharmacy ensuring safety of the prescription...

The ****tiest part is that in Canada we don't track data like this really well so it is even more difficult to demonstrate the limitations of such a band-aid approach.

 

 

I am an RN, and feel that if this ever got pushed through there would have to be major revamps to the curriculum and current job description. They'd have to severely rebalance the current workload. However, in BC at least, there is currently a BIG push for LPNs to have a larger scope of practice (taking over all IV medications, for example). My thoughts are that if the LPN scope/education is expanding and changing at this rate, the RN's role is going to change as well to reflect that.

Currently I don't believe many nurses are competent to perform diagnosis. However, I work on a specialized unit and yes, there are some amazing nurses who regularly make better calls on decisions than patient's GPs outside the hospital do. We require post-degree training to work on our unit, and many RNs on different units also require this (ICU, PARR, Cardiac, to name a few). On a unit-specific basis, we are often more knowledgable in our fields than many of the GPs who do not routinely see patient's in these areas or levels of acuity. Yet we could never go out into the community and do the GPs job. And RN's from unspecialized units I don't think are often anywhere near the level of making diagnoses. It's a matter of specialization and further education between RNs at this point, and if diagnosis gets brought in there would have to be big changes within the BScN program to reflect that. Not just post-degree training. Over the last 10 years there have been huge changes to the RN and LPN programs, and I wouldn't be surprised to see this scope of practice continue to expand and the education change further.

There's talk of pharmacists getting rights to diagnose too eventually, but that's another topic

Just my 2 cents.

[JacquiDent]

The interviewee in the link I posted mentioned RNs in nursing homes prescribing antibiotics for UTI, not really sure if a nursing home is as specialized in acute complex care such as ICU and if nursing home RNs get additional training in making primary care diagnosis. I can imagine - or my hypothesis is that - said RNs messing up when prescribing ABX's to nursing home residents with comorbidities including renal failure (talk about ABX toxicity, further frying their kidneys etc...) and to make things worse nursing homes don't have the kind of pharmacy coverage that acute care units have so there is no additional level of pharmacy ensuring safety of the prescription...

The ****tiest part is that in Canada we don't track data like this really well so it is even more difficult to demonstrate the limitations of such a band-aid approach.

 

RNs in nursing homes usually carry no additional training :s I certainly wouldn't trust most I have met who work in those settings to be diagnosing/prescribing. It is a very 'unregulated' area, as there's less interaction with physicians, management, pharmacy, etc.

I totally agree with you, I don't think they should be prescribing like that. I think if they move towards nurses prescribing, it should only be in certain hospital settings where appropriate supports and resources are in place.

[NLengr]

I wouldn't trust the nurses on the Urology floor of my center to treat a UTI correctly. From my interaction with them (the uro floor admits several types of surgical patients at my center) they simply lack basic knowledge of a bread and butter topic like UTI diagnosis and management. The vast majority don't know basic guidelines and knowledge such as:

 

1. Don't culture an asymptomatic indwelling foley cath (It'll always be +)

2. Don't treat a positive indwelling culture unless symptoms

3. Macrobid has NO tissue penetration. Trying to treat things like pylonephritis or febrile UTI with macrobid can rapidly lead to urosepsis. Sepsis rapidly kills people. This is a major issue.

4. Men require a different duration of antibiotics for UTI.

5. Men with a UTI (certainly a recurrent UTI) require urological work up

 

That's just simple stuff I have heard off the top of my head from a floor that specializes in the urinary tract. I don't blame the nurses. The concepts aren't hard, but they never got the education. Even your most green family doc should know that stuff.

 

Now we are proposing having even less specialized chronic care nurses managing UTI's in fragile old patients who usually have a much larger percentage of urologic issues, medications and commodities.

 

UTI's seem easy. 90% of the time they are. Just like all of medicine. It's the 10% that aren't what makes medicine something you need 6-10 years of very intense highly demanding training to practice.

 

This idea has the potential to be a disaster. It's an attempt by a incompetent provincial government to cut healthcare costs at the expense of the public.

[ldnk]

RNs in nursing homes usually carry no additional training :s I certainly wouldn't trust most I have met who work in those settings to be diagnosing/prescribing. It is a very 'unregulated' area, as there's less interaction with physicians, management, pharmacy, etc.

I totally agree with you, I don't think they should be prescribing like that. I think if they move towards nurses prescribing, it should only be in certain hospital settings where appropriate supports and resources are in place.

 

There are a lot of nurses I would be more than happy to trust making diagnoses/prescribing basic antibiotics. Especially the ones who have been on the floor for a while and know what they are doing cold. Working through clerkship, their help has been invaluable at times for additional training/perspective.

 

On the flip side you get calls from nursing homes where there are no dedicated physicians on site and then people who make statements like

 

Nurse: "can we get a chest x-ray/give lasix on Mr. Johnson. He's not breathing well."

Me: what are his vitals

Nurse: I'm not sure, do you want them?

Me: Sure, did you listen to his chest?

Nurse: No

 

Is it anecdotal and unfair to the very talented nurses who would be capable of this. Absolutely. But I'd be very concerned for the patients who get medical care from people like that.

[Robin Hood]

If pharmacists and nurses start diagnosing and prescribing, what will then make them different from physicians?

[Tacrolimus]

If pharmacists and nurses start diagnosing and prescribing, what will then make them different from physicians?

 

...that is already happening in Alberta, and I'm glad it is. The Pharmacists that I have worked with know what they are doing, and often scratch their head when a Physician is prescribing something that doesn't fit well for the patient. Since it takes a lot of time and effort, they usually correct only major things and just let minor things go (it isn't easy to change what the physician has done but definitely do-able).

[leviathan]

There are a lot of nurses I would be more than happy to trust making diagnoses/prescribing basic antibiotics. Especially the ones who have been on the floor for a while and know what they are doing cold. Working through clerkship, their help has been invaluable at times for additional training/perspective.

 

On the flip side you get calls from nursing homes where there are no dedicated physicians on site and then people who make statements like

 

Nurse: "can we get a chest x-ray/give lasix on Mr. Johnson. He's not breathing well."

Me: what are his vitals

Nurse: I'm not sure, do you want them?

Me: Sure, did you listen to his chest?

Nurse: No

 

Is it anecdotal and unfair to the very talented nurses who would be capable of this. Absolutely. But I'd be very concerned for the patients who get medical care from people like that.

Read NLengr's post about abx for UTI. Good example how there are lots of exceptions to the rule that a nurse isn't educated on. And that's just a very simple diagnosis too and s/he could have mentioned things like understanding antibiotic susceptibility patterns for the area, interactions with other meds, ruling out structural problems, considering the difference between a simple and complicated UTI, ruling out prostatitis in a man etc. Again I shouldn't even have to say it, but it's no fault of the nurses because it's not part of their education or their scope. That's why the idea of expanding someone's scope without expanding education makes no sense. If you do expand their education, then why not just go to medical school.

[AtomSmasher19]

The problem I have with giving nurses more power is that it simply has the effect of moving the care everyone receives down-market. If the nurses are making diagnoses, who's going to do the b!tchwork? An even less skilled employee. So instead of doctors making diagnoses and nurses doing b!tchwork, we now have nurses making diagnoses and minimum wage people doing b!tchwork. In the end, the patient loses, and hospital administrators and bureaucrats win because now they have more money to pay themselves.

[laladeedee]

The problem I have with giving nurses more power is that it simply has the effect of moving the care everyone receives down-market. If the nurses are making diagnoses, who's going to do the b!tchwork? An even less skilled employee. So instead of doctors making diagnoses and nurses doing b!tchwork, we now have nurses making diagnoses and minimum wage people doing b!tchwork. In the end, the patient loses, and hospital administrators and bureaucrats win because now they have more money to pay themselves.

 

That's what I was thinking too!

[JacquiDent]

The problem I have with giving nurses more power is that it simply has the effect of moving the care everyone receives down-market. If the nurses are making diagnoses, who's going to do the b!tchwork? An even less skilled employee. So instead of doctors making diagnoses and nurses doing b!tchwork, we now have nurses making diagnoses and minimum wage people doing b!tchwork. In the end, the patient loses, and hospital administrators and bureaucrats win because now they have more money to pay themselves.

 

What an incredibly ignorant and degrading thing to say.

[Belle_MD]

What a joke! That IS ignorant...sorry to burst your bubble but I personally don't do b*tch work!

 

OH and I do prescribe all different forms of birth control, and antibiotic treatments for STIs and BV. And Im more than confident in my skills, training and knowledge. And when Im an MD, I wont degrade or belittle nurses and I will respect their knowledge and training.

 

I have worked with exceptional nurses in critical care who are the ones telling MDs what to do and to get their sh*t together. So how about we stop generalizing and stereotyping? Thanks.

[Robin Hood]

What an incredibly ignorant and degrading thing to say.

 

AtomSmacher is a troll.

[leviathan]

And when Im an MD, I wont degrade or belittle nurses and I will respect their knowledge and training.

It's not belittling or degrading to say that nurses have the education of nurses, and don't have the education of doctors. There are some trolls in here saying inappropriate stuff, not sure if you were referring to those people.

[JacquiDent]

It's not belittling or degrading to say that nurses have the education of nurses, and don't have the education of doctors. There are some trolls in here saying inappropriate stuff, not sure if you were referring to those people.

 

Quite a few people have made very generalized statements about nursing education without sincerely acknowledging varying curriculums/post-degree education. And even less have acknowledged the fact that should further diagnosis be brought into our scope of practice the education would likely change to reflect that.