Diagnosis By Nurses

[leviathan]

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.

The changes to education would basically require the nursing school to become a medical school, so it doesn't make sense to me as they'd no longer be nurses. We have nurses for a reason; we need their skills and expertise at nursing. If we don't have enough staff to make diagnoses and treatment plans, then the solution is to train and hire more doctors, not try to take away our limited supply of nurses and train them to be pseudodoctors.

[JacquiDent]

The changes to education would basically require the nursing school to become a medical school, so it doesn't make sense to me as they'd no longer be nurses. We have nurses for a reason; we need their skills and expertise at nursing. If we don't have enough staff to make diagnoses and treatment plans, then the solution is to train and hire more doctors, not try to take away our limited supply of nurses and train them to be pseudodoctors.

 

It doesn't mean nurses would no longer be nurses, just as pharmacists who prescribe are still pharmacists. Diagnosis isn't the be all end all of medicine and the only defining skill of a doctor. Allowing other healthcare professionals to take on the 'easier' cases would allow physicians to focus on the more complex ones. It's taking some of the strain off of a strained system. In cities it isn't particularly necessary, but in underserved areas it is sadly what the system needs. We have too many GPs who are severely overworked and taking on too many patients, or choosing not to open their own practice and solely practice out of walk-ins. NPs, etc. allow for a longer-term follow-up with patients in areas where a family doctor isn't available.

It's a similar situation as to implementing nurse practitioners. You likely wouldn't see all nurses diagnosing in all areas, or at least their range of diagnoses would be limited (as it currently is for PHNs and NPs, and for pharmacists who can diagnose). In future we are going to see a greater and greater overlap of skills, it is just something that will require further regulation and changes. We are an evolving system, and changes to our scopes/education/etc doesn't mean we are no longer what we we originally were. Healthcare is continually evolving and changing, and as our treatment options, population needs, etc change so too will our jobs.

Just as RNs feel threatened by LPNs at times, I can understand why physicians feel threatened by it. But, the education is changing to reflect that and so too will job descriptions. It would be great to see more seats opened up in medical schools, but that's a costs etc factor that we wont see occurring in substantial numbers quite yet. For now the more financially feasible option in a government-funded system is to expand the scopes of those who are cheaper to train and in greater supply, and who have more people available to give said training.

Back in the 50s you didn't see nurses doing all that we do now. We've taken on a bigger and bigger role throughout the century, it doesn't mean we are not now an entirely different profession. Same with many others in healthcare. We're simply an evolving system.

[NLengr]

Allowing other healthcare professionals to take on the 'easier' cases would allow physicians to focus on the more complex ones.

 

I hate the expression "simple cases". It's used inhese situations as a dishonest saying to push a political agenda. There is a surgical saying:

 

"the only simple surgeries are the ones that have already been completed"

 

Its the same for anything in medicine. You don't know something is "simple" until it's over and you know there were no complications. You cant tell from the beginning that a patient will be simple. Patients don't come with a difficulty index like an exam question. There is a reason I talk about death for the consent for every single patient I will operate on, regardless if they are having a AAA repair or an inguinal hernia repair under local.

 

You can't say "well X will only see simple cases" as a justification for giving someone access to a scope of practice because you can't tell who the simple cases are overland done with.

 

If this goes through there will have to be an overhaul to nursing education. Again, right now it's not even close to adequate to allow prescribing. And then the question also become what to do with the RN's working now? Are we making them do night courses to prescribe or do we grandfather them in (even though they may lack the adequate education)?

 

By the way, I like NP's. I think they have an adequate education to work a limited scope. I do not believe this exists for RN's, and nobody pushing these changes publicly has demonstrated this either.

[chrail]

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.

 

This is very misinformed and misleading. You don't prescribe these things (BCP, Abx) as an RN or PHN, you follow medical directives (that give you choices based on symptoms, culture reports, etc.). These are very different things.

[Belle_MD]

Yes absolutely under medical directives, no one is misleading here. The whole point of my post is that nurses don't do b*tch work and that a nurse is not a nurse is not a nurse. Some have additional education and training and skills. Just because we have med directives doesn't mean we don't use judgment or critical thinking skills. I do paps, I do thorough assessments to determine if OCP is appropriate for my patients and yes I can write a prescription for OCP based on my assessment. I'm not attacking anyone on here except the nasty comments about b*tch work, I don't come on here to fight with people i just don't think comments like those are justified.

[JacquiDent]

I hate the expression "simple cases". It's used inhese situations as a dishonest saying to push a political agenda. There is a surgical saying:

 

"the only simple surgeries are the ones that have already been completed"

 

Its the same for anything in medicine. You don't know something is "simple" until it's over and you know there were no complications. You cant tell from the beginning that a patient will be simple. Patients don't come with a difficulty index like an exam question. There is a reason I talk about death for the consent for every single patient I will operate on, regardless if they are having a AAA repair or an inguinal hernia repair under local.

 

You can't say "well X will only see simple cases" as a justification for giving someone access to a scope of practice because you can't tell who the simple cases are overland done with.

 

If this goes through there will have to be an overhaul to nursing education. Again, right now it's not even close to adequate to allow prescribing. And then the question also become what to do with the RN's working now? Are we making them do night courses to prescribe or do we grandfather them in (even though they may lack the adequate education)?

 

By the way, I like NP's. I think they have an adequate education to work a limited scope. I do not believe this exists for RN's, and nobody pushing these changes publicly has demonstrated this either.

 

I do agree, I should have rephrased that line. We don't ever know when something will become a much more complex case. I just meant in general there would likely be guidelines as to what RNs could diagnose.

As for the current RNs, I imagine it would go similarly to when they brought in degree requirements for RNs. Many of the RNs at the time only had a diploma and were forced to either retire or return to school, although again it may depend on what area they're working in.

[A-Stark]

I think the notion of "guidelines" for diagnosis misses the point. If you're thinking about a differential, you can't very well be constrained by an arbitrary scope to consider some possibilities and not others. This isn't about NPs but "regular" RNs, some of whom work in highly acute areas requiring considerable experience and skills.

 

But even in the ICU I've encountered an RN who thought a patient with a TCA overdose needed an EEG to assess his myoclonus, and that it was a good idea to consult neuro on a Saturday morning for it. (And she went ahead and called the neuro resident on call even after the staff said it wasn't necessary on rounds, causing an awkward call later where we had to tell the poor resident that, no, we hadn't consulted her.)

[AtomSmasher19]

Yes absolutely under medical directives, no one is misleading here. The whole point of my post is that nurses don't do b*tch work and that a nurse is not a nurse is not a nurse. Some have additional education and training and skills. Just because we have med directives doesn't mean we don't use judgment or critical thinking skills. I do paps, I do thorough assessments to determine if OCP is appropriate for my patients and yes I can write a prescription for OCP based on my assessment. I'm not attacking anyone on here except the nasty comments about b*tch work, I don't come on here to fight with people i just don't think comments like those are justified.

Let's be honest here. You're not the brains of the team - you have been trained to be a grunt

 

Now, you're asking for permission to do things even further from your training, like a 16 year old who just got his drivers lisence and wants to drive on the autobahn.

[thebouque]

Let's be honest here. You're not the brains of the team - you have been trained to be a grunt

 

Now, you're asking for permission to do things even further from your training, like a 16 year old who just got his drivers lisence and wants to drive on the autobahn.

 

Seriously this kind of attitude has to stop. Even if you're being a troll, there are limits.

[masterb]

Unfortunately patient safety is not at the center of this sort of decision making. What is at the center is cost cutting, superficial patient satisfaction by expediting the care they receive using band-aid solutions (sure some patients might be happy but just because there is a physician shortage or ?we can't afford physician care, doesn't mean we should expose patient to potentially sub-standard and unsafe care) and profession centric turf war. Yes, there might be some super-competent, very intelligent RNs who might be able to diagnose really well independently, but is this a scalable solution? are adequate safety measures going to be taken into account or are nursing homes, hospitals etc just going to sweep mishaps under the carpet when problems do occur? I wouldn't trust a nursing home RN to diagnose my frail elderly family member's UTI especially if the next incorrect ABX dose is going to tip the scale over and cause their frail biological systems to crash. With regards to respecting an RN's scope, absolutely, they play a vital part in the team. At times RNs even in acute complex settings might make a valid and crucial suggestion to ordering an important medication but ultimately it is the physician who has to work out, by considering all possibilities, if that medication is the right one and takes responsibility for prescribing it, in the off chance that the medication is not the right one, the physician is responsible for correcting it. An RN might correctly suggest a vasopressor therapy to improve cardiac output but ultimately the physician has to use his/her knowledge to determine if the patient has enough fluid volume for those therapies to work in addition to ruling out inappropriateness of those therapies regardless of various measurements pointing out to the need for vasopressor therapy. I understand that this may be a complex situation but even in simple cases, medical complexities need to be considered in order to prevent them. RNs because of their training might not be able to think through the medical complexities adequately. Just because they can make the right call, doesn't mean they can think through the medical complexities.

[leviathan]

An RN might correctly suggest a vasopressor therapy to improve cardiac output but ultimately the physician has to use his/her knowledge to determine if the patient has enough fluid volume for those therapies to work in addition to ruling out inappropriateness of those therapies regardless of various measurements pointing out to the need for vasopressor therapy.

Just a pet peeve of mine, but a vasopressor will NOT improve your cardiac output, it will decrease it. The only exception would be if you improve coronary perfusion pressures and contractility, but that's debatable as it's at the cost of a higher afterload.

[futureGP]

what to do when you got 2 giants to deal with?

 

make them fight each other

 

 

 

 

at the end of this, lose-lose for nurses/doctors, but win for administrators

[Skylerate2]

Let's be honest here. You're not the brains of the team - you have been trained to be a grunt

 

Now, you're asking for permission to do things even further from your training, like a 16 year old who just got his drivers lisence and wants to drive on the autobahn.

 

Exactly right. But of course, the nurses will argue and fail to see reason while they arrogantly overstate thier capabilities. Next they'll want to perform surgery!

[hexonu]

Let's be honest here. You're not the brains of the team - you have been trained to be a grunt

 

Now, you're asking for permission to do things even further from your training, like a 16 year old who just got his drivers lisence and wants to drive on the autobahn.

 

I'm just shuddering at the thought of this individual becoming a physician and if he/she is already one then I pity the interdisciplinary team that is forced to work with them. An attitude like that is why your role of gatekeeper in healthcare is dwindling.

 

To chime in though, RN's (which is what is being debated here) usually don't do the grunt work if you want to even call it that. RN's are constantly using critical thinking skills and assessment. We're the ones who stop physicians from killing patients, it's reported that 100,000 of people die every year due to medical errors largely made by physicians. So yes going to school for 8+ years does not make you infallible. We've all encountered idiot MD's and RN's alike but to paint all RN's with the same brush I think is wrong. I also don't think it's a stretch to increase the scope of practise for RN's as they are with the patient about 90% of the time. I hardly see physicians doing proper assessments they usually go off what the nurse reports and then go through the motions and prescribe generic treatments.

[masterb]

Just a pet peeve of mine, but a vasopressor will NOT improve your cardiac output, it will decrease it. The only exception would be if you improve coronary perfusion pressures and contractility, but that's debatable as it's at the cost of a higher afterload.

 

Thanks for pointing that out, I wasn't really thinking through it after a hectic day, was just typing fast to make a point.

[NLengr]

We're the ones who stop physicians from killing patients, it's reported that 100,000 of people die every year due to medical errors largely made by physicians. So yes going to school for 8+ years does not make you infallible. We've all encountered idiot MD's and RN's alike but to paint all RN's with the same brush I think is wrong. I also don't think it's a stretch to increase the scope of practise for RN's as they are with the patient about 90% of the time. I hardly see physicians doing proper assessments they usually go off what the nurse reports and then go through the motions and prescribe generic treatments.

 

Well let's be honest, it's a complex system of checks that prevents medical errors, it's not one set of people. And our complex system doesn't do a great job anyway.

 

Also, any evidence the errors are mostly physician based? From my experience (in healthcare and other organizations as an engineer) errors are a result of a breakdown at multiple levels in a complex system. There is rarely a single failure point.

[aaronjw]

I'm just shuddering at the thought of this individual becoming a physician and if he/she is already one then I pity the interdisciplinary team that is forced to work with them. An attitude like that is why your role of gatekeeper in healthcare is dwindling.

 

To chime in though, RN's (which is what is being debated here) usually don't do the grunt work if you want to even call it that. RN's are constantly using critical thinking skills and assessment. We're the ones who stop physicians from killing patients, it's reported that 100,000 of people die every year due to medical errors largely made by physicians. So yes going to school for 8+ years does not make you infallible. We've all encountered idiot MD's and RN's alike but to paint all RN's with the same brush I think is wrong. I also don't think it's a stretch to increase the scope of practise for RN's as they are with the patient about 90% of the time. I hardly see physicians doing proper assessments they usually go off what the nurse reports and then go through the motions and prescribe generic treatments.

 

In my current experience that I'm basing current judgement on is that nurses seem to be doing a very crappy job of charting which is screwing the effectiveness of physician orders because he's not getting all the relevant information.

[thebouque]

I'm just shuddering at the thought of this individual becoming a physician and if he/she is already one then I pity the interdisciplinary team that is forced to work with them. An attitude like that is why your role of gatekeeper in healthcare is dwindling.

 

To chime in though, RN's (which is what is being debated here) usually don't do the grunt work if you want to even call it that. RN's are constantly using critical thinking skills and assessment. We're the ones who stop physicians from killing patients, it's reported that 100,000 of people die every year due to medical errors largely made by physicians. So yes going to school for 8+ years does not make you infallible. We've all encountered idiot MD's and RN's alike but to paint all RN's with the same brush I think is wrong. I also don't think it's a stretch to increase the scope of practise for RN's as they are with the patient about 90% of the time. I hardly see physicians doing proper assessments they usually go off what the nurse reports and then go through the motions and prescribe generic treatments.

 

 

While I think that the scope of practice for RNs should be expanded (to what degree it's still to be determined), I've never encountered a physician who doesn't perform a proper assessment and who relies purely on what the nurse did. Often nurses call me at night because of shortness of breath or O2 desaturation and they are never able to describe a proper pulmonary auscultation. I think it's all right, it's not really their scope of practice, but it's totally false to say that physicians ''hardly do proper assessment and they go off what the nurse reports''. On most wards, what nurses report usually go like this: pt X has bad veins so prescribe a picc line, pt X is agitated so we'd like some ativan/haldol etc. Or maybe you were referring to the actual written report notes saying: 10: 25 pt X ate 80% of his plate, 10: 45 pt X is sleeping well, 12:05 pt X urinates 400cc etc. Those reports are VERY useful, don't get me wrong, but they're not sufficient to give proper medical care, so I don't see how a doctor would just rely on those. Finally, medical errors are made by everybody, including physicians and nurses. While it might be true that physicians are responsible for most mistakes, it's because they have incomparably more responsibilities than nurses. Keep in mind that a lot of responsibilities come with prescribing privileges. In my province, nurses are allowed to prescribe physical restraints. However, they often ask us to prescribe the restraints because they don't want to deal with the responsibilities that come with the prescription if something goes wrong.

 

That's it for now, peace

[futureGP]

I'm just shuddering at the thought of this individual becoming a physician and if he/she is already one then I pity the interdisciplinary team that is forced to work with them. An attitude like that is why your role of gatekeeper in healthcare is dwindling.

 

To chime in though, RN's (which is what is being debated here) usually don't do the grunt work if you want to even call it that. RN's are constantly using critical thinking skills and assessment. We're the ones who stop physicians from killing patients, it's reported that 100,000 of people die every year due to medical errors largely made by physicians. So yes going to school for 8+ years does not make you infallible. We've all encountered idiot MD's and RN's alike but to paint all RN's with the same brush I think is wrong. I also don't think it's a stretch to increase the scope of practise for RN's as they are with the patient about 90% of the time. I hardly see physicians doing proper assessments they usually go off what the nurse reports and then go through the motions and prescribe generic treatments.

 

i hear a lot of these vague statements

 

it's very convincing... if you see it from the nurses perspective.

 

i challenge your statement saying you hardly see physicians doing proper assessments and go off what the nurse reports.

 

If you do see that you can accuse him of malpractice and see what he says. if he was really basing all his decisions on assessments by nurses then he deserves having his license revoked becuz he won't even bother doing a real medical assessment.

 

plus i didnt know nurses could do a proper cardio/resp/abdominal exam to pick up pathological findings and interpret that incorporating necessary anatomy/physiology/pathophysiology and derive a differential diagnosis and suggest an assessment plan for laboratory orders, imaging, additional biochemical studies etc.

 

if nurses could do that, they won't need to be a nurse, they can just call themselves doctors and be done with.

 

i really hate it when people say nurses can treat the easy cases. Every case is difficult unless proven otherwise. For every single patient you would do a proper history/physical and based on those plan for assessment and derive a treatment plan based on most likely diagnosis.

 

it's not as simple as, oh patient coughs up green stuff, let's give antibiotics prob has infection. for everyone of those patients, every doctor would rule out the ominous causes until he's quite confident that it is what it is. and depending on the amount of experience it could simply be a 2 min history/physical, or a 15 min history/physical (esp. if you're a medical student on-training).

[A-Stark]

To chime in though, RN's (which is what is being debated here) usually don't do the grunt work if you want to even call it that. RN's are constantly using critical thinking skills and assessment. We're the ones who stop physicians from killing patients, it's reported that 100,000 of people die every year due to medical errors largely made by physicians. So yes going to school for 8+ years does not make you infallible. We've all encountered idiot MD's and RN's alike but to paint all RN's with the same brush I think is wrong. I also don't think it's a stretch to increase the scope of practise for RN's as they are with the patient about 90% of the time. I hardly see physicians doing proper assessments they usually go off what the nurse reports and then go through the motions and prescribe generic treatments.

 

Don't underestimate the importance of sound, attentive nursing care in avoiding adverse outcomes, e.g. the role of keeping the head of ICU beds at 30 degrees to reduce the risk of VAP.

 

In any case, time spent with the patient is somewhat immaterial (or else sitters would know patients best). A physician (or even a medical student) might cover the same patient throughout his whole admission, while the patient might never have the same nurse more than once. None of this says anything about whose scope of practice should encompass one thing or another.

 

From a "medical" perspective, the clinical training of even NPs is only really adequate within more narrow areas. They can be excellent for wellness exams and application of guidelines and screening in primary care, but inadequate at basic generalist assessment. I'm sure I've mentioned it before, but one telling experience I had was with an NP who worked on the regular cardiology ward of a major academic hospital in Ontario. She was very good - great, really - at functioning as a sort of very efficient housestaff on the team and managing the fairly narrow range of patient presentations (stable CHF, NSTEMIs, patients waiting for CABGs), but had no idea how to manage something like an acute lower GI bleed in an otherwise stable patient. Without even doing a DRE (or apparently any rectal exam at all), she arranged an urgent CT which unsurprisingly showed diverticulosis, which should be number 1 on the differential anyway in a geriatric patient.

 

Unfortunately, she made several basic errors. First, she failed to do an adequate physical exam. Second, she ordered a test which provided essentially no information about the lumen (it was not CT colonography). Third, the test that was ordered seemed to betray a lack of consideration of a proper differential diagnosis. If the source of bleeding was indeed a polyp or colorectal cancer, it was absolutely the wrong management. Certainly there will be physicians around who make poor clinical management decisions as well, but anyone looking for more "scope" of practice should already be at the highest level of competence. That's not so say this NP wasn't - she was, and I really enjoyed working with her - but you don't get adequate clinical judgement without considerable medical clinical experience (i.e. clerkship and residency), and neither undergraduate nursing nor NP clinical rotations are even close to equivalent.

 

ETA: With respect to "easy" or "simple" cases, the assessment of bright red bleeding per rectum absolutely falls into that category. I could go on with other examples (e.g. not knowing the difference between cholelithiasis and cholecystitis), but that would belabour the point.

[maritimer]

Allowing other healthcare professionals to take on the 'easier' cases would allow physicians to focus on the more complex ones. It's taking some of the strain off of a strained system. In cities it isn't particularly necessary, but in underserved areas it is sadly what the system needs. We have too many GPs who are severely overworked and taking on too many patients, or choosing not to open their own practice and solely practice out of walk-ins.

 

Isn't this why there are NPs and PAs, though-rather then extending and RNs scope? Wouldn't it make more sense for an RN who wants to do more to become an NP, PA or MD instead?