Differences in practice: experts and novices. Are you learning from one another?

[BlueDevil,DNP, DNP, RN]

There are two NPs in my practice, myself and a woman I'll call Zelda. I am a FNP, and have been in practice for 3 years. Zelda is an ANP and has been in practice for 9 years. All of her experience is in internal medicine.

Zelda, by nature, has a somewhat closed mind. This applies to all things, not just the practice of our art/science. She does not consider points of view contrary to her own and in my experience does not change her mind when confronted with new evidence. She is very competent. It happens from time to time, that I have occasion to see a patient of hers if she is out of the office for some reason. Zelda does a number of things I would not do. For instance, she treats all sinus infections with antibiotics. We have discussed this several times, and she feels the current EBP is in error. She knows that she feels better when she takes a z-pack, all of her patients feel better, and that at some point it will turn out that the evidence was "wrong" and the recommendation will reverse itself and everyone will have to admit she was right all along. She feels that when I see her patients, I should do for them what I know she would do. I disagree. They are seeing me, not her. I follow EBP. If they have had symptoms for 2 days and have not tried any conservative measures, yada, yada, yada, they are not getting an antibiotic. This has been a point of contention for a while.

A patient of hers came back from the diabetic educator saying they told her an A1c of 8.0 was OK. She went berserk and was about to call the BC-ADM and tell her what an idiot she was; I let her know that that is the new recommendation for A1c in older adults. She thinks it is ridiculous and announced she will refuse to follow them and isn't sending anymore patients to the educator. This sticking her head in the sand routine is beginning to get frustrating!

We went through this again last week, only over antibiotic prophylaxis for a benign flow murmur before a simple dental cleaning. Under no circumstances was I going to prescribe for that, and it turns out, she always does, regardless of current guidelines. Her opinion "better safe than sorry." The patient was extremely upset that I refused and called her at home, and Zelda called it in for the patient. I am not upset about that, that is Zelda's choice. I think it is the wrong one, but it's on her.

We talked it out later, and Zelda and I are OK. She does feel frustrated that I "don't capitulate to her greater experience in these things." I learn a lot from her. She does have a lot of good tips, and has been a lot of help to me in the last three years, and I am appreciative. But I am more up to date on a lot of things than she is, I read more, study more (I have to, I have a much steeper learning curve!) and investigate more. I have some things I could share with her, but she just is not willing to learn anything new or unlearn anything she learned 10 years ago.

So, if you are a novice NP like me, how do you navigate these types of issues? And if you are a more experienced NP and see it a bit from the other point of view, what advice do you have for me? Or what are your thoughts in general about how colleagues with varying experience and backgrounds learn from one another?

[traumaRUs, MSN, APRN]

I'm in a practice with four other mid-levels: two FNPs have been with the practice for 10 years, one PA has been here 12 years and one PA has been here 11 years. I'm the newest with 6 years. Four of us do the same job: round on outpt dialysis patients. We frequently collaborate with each other. We all strive to be up to date and we all read a lot to stay current. Although we are nephrology practice, few primary care offices like to see dialysis pts so we do a quasi-sorta of primary care: if its something we can easily care for: ie URI, pneumonia, UTI, or sinusitis, we care for it. If its something GYN-related or requires a more in-depth exam, we refer out to the PCP or an urgent care. My pts are very well educated to call us before filling any scripts as many providers are not aware of renal dosing.

[rlianne]

I think Zelda is being ridiculous. Experience does not trump evidence based practice! Things change and she should be open to that. It sounds like you are doing the best you can while still trying to keep a good working relationship. I have 7 years experience myself and yet I am still constantly reading and trying to keep up with the literature. I've precepted NP and PA students in the past and THEY would on occasion teach ME something b/c they are learning all the latest evidence based guidelines. You are never to old to learn and it is unfortunate for Zelda's patients that she is so closed minded...let's hope she doesn't hurt someone in the future.

[pedspnp]

Zelda sounds like the md in my office. Every child it seems who comes in with a snotty nose and cough for two days leaves on Cefzil . I don't get it, but he keeps reminding the staff he has been a pediatrician for 10 years. I don't even consult him anymore after he told a parent a child had measles and reccommended I put the child on a abx for a OM because the tm was slightly red( kid was screaming his head off) turns out he had a heat rash and the only reason he looked at the child was because mother asked for another opinion and he was the only other provider there. And no I did not put the child on abx .

[Corey Narry, MSN, RN, NP]

I would continue to practice the way you are doing based on what your conscience tells you is right and with a solid base of evidence behind it. The basic tenet is to do no harm and by adhering to that you know you are practicing safely. That I would do even if you have to occasionally cover for Zelda's patients. As providers, we answer to whatever consequences our actions bring and you do whatever will protect your license and reputation. Zelda can do whatever she wishes because ultimately, she will face the consequence of her actions. She may feel that her actions do no harm but in the long run, regulatory bodies do monitor our actions and sooner or later she may have to explain why she did the things she did to a regulatory entity. Luckily, in my practice evidence is always invoked whenever we make decisions but from time to time, we are also faced with disagreements especially between different specialties co-managing specific patients and between the same ICU attendings who cross-cover. The NP's try to side with the voice of reason and people are typically very civil and professional around here (seems to be a West Coast thing).

[alwayslookingnp]

I think Zelda is being ridiculous. Experience does not trump evidence based practice! Things change and she should be open to that. It sounds like you are doing the best you can while still trying to keep a good working relationship. I have 7 years experience myself and yet I am still constantly reading and trying to keep up with the literature. I've precepted NP and PA students in the past and THEY would on occasion teach ME something b/c they are learning all the latest evidence based guidelines. You are never to old to learn and it is unfortunate for Zelda's patients that she is so closed minded...let's hope she doesn't hurt someone in the future.

rlianne- good post! I think this is a phenomena that plagues nursing in general not just NPs. I have been an NP for 5 years but in nursing school they chipped out my diploma on a stone tablet! In the old days a "good nurse" was one who could get all the charting done, all the meds passed and everyone fed and bathed by the end of the shift. No more- thank god! Nuses are expected to actually have some clincal knowledge and expertise. I think some of the older nyurses are resistant to change because they are comforatable in the old model and are not sure where they fit in to the newer model.I think we need to respect these NPs and where they have been but we all need to move forward.

Practicing evidence based medicine (EBM) is the only thing that will give us credibility. Look at it this way... I was taught in nursing school not to wear gloves when giving an enema because it makes the patient feel "dirty." Good Lord!- That is NOT EBM! So we need to be able to defend our actions by EBM. No longer is "that is the way I was taught, or that is the was Mary does it" acceptable. This kind of thinking is one of the biggest critisims medicine has of Nursing (and rightly so.)

That being said it is sometimes a fine line you walk as far as patient satisfaction. Even with all kinds of explanations why folks don't need antibiotics there are studies that support that the more tests that are ordered the higher patient satisfaction is. If you donn't give azith for URI, do you give loratidine or tessalon, maybe something to help the patient sleep? You have to use your own practice guidelines but these are strategies that some providers use.

As far as alienating the nutrition provider....sigh....when will Nursing ever learn to collaborate??? And collabiorate is the rightb word becazuse we need to collaborate with everybody.Nutrition, nursing, PT, housekeeping, ect... We need to create as much good will as possible most especially in today's climate. (Have you read th Institute of Medicine's recommendation for the future of nursing?)

Take care Blue, you sound exactly like the kind of provider I would love to work with.

[ktwlpn, LPN]

You are the FNP I would want to consult.I'm in LTC and see what happens with overuse of antibiotics. I've been out of school for over 20 years and I pride myself on the fact that I am still learning and look forward to continuing to do so especially when I am mentoring new grads.It's a win-win for me.I feel sorry for people like your co-worker.It must be so difficult to live in their world,one in which no-one lives up to their expectations.It must be so frustrating.

[That Guy, BSN, RN, EMT-B]

I read this one of 2 ways. The first being thanks for standing up for what you think is right nad are trying to do what the evidence shows. Way too many get antibiotics for nothing and it is creating a huge problem. I just think of how many times I have to explain to people why they dont need anything when leaving the ER.

The other way I look at it is how many times have we been doing things for so long because we though and evidence showed us it was right, only to find out we were way off. Either way I think what you are doing is right and keep going along with it.

PS. I would have loved to call you when I was working the floor. You sound like you know your stuff and are after the best interest of the pt.

[BlueDevil,DNP, DNP, RN]

I wasn't trying to pat myself on the back and imply I know more than my colleague. That is certainly not the case. Those were just a few examples that have come up in the last week to ten days that have frustrated our working relationship a bit, and while we worked it out between us it got me thinking. I sometimes wonder if I am too rigid in sticking to what I was taught in school and not taking advice from my colleague that has been in the trenches. If she demonstrated what I considered a reasoned approach regarding decisions to cast aside EBG in favor of her own judgement in special circumstances, well that would be one thing. We all know one size does not always fit all and there is no substitute for clinical judgement based on patient history, presentation and modifying factors. That isn't the case here. She simply isn't keeping up-to-date with the literature. I make mistakes all the time, but they are mistakes borne from inexperience, not plain stubbornness! It frustrates me because there is so much lost opportunity to really help one another play up the others' strengths, and it is such a shame not to be taking advantage of that. As this is as much a function of her personality as anything, I don't think it is going to change.

[kristikkc]

I agree with the abx. With my own experience with chronic sinus problems, if I use OTC meds and other methods, I will not need an abx. Comfort measures and treating the symptoms sometimes are what is needed

[Aniva]

Antibiotics are being overly prescribed and providers are not reading the latest guidelines and studies... I'm in a similar work environment with another experience NP and I'm having the same issue. I just do my own thing and let her do hers. If I get one of her patients, I try to explain the pathology and rationale for my management plan. If they get upset with me for not prescribing an antibiotic for 1 or 2 days of cold symptoms, oh well. A physician who was my old preceptor discussed this issue with me and a few residence. It's a big issue, but he told us to "practice good medicine" when we're out in the world-and I intend to do the best I can regardless of what the other NP is doing. Everything we do and the medical decisions we make have to be justified. I'm sure then they were in school, they were told to pass out antibiotics like it was candy for reasons like "prophylactic" or "better to be safe than sorry", which is nuts. All drugs have risks.

[RockSolid]

" A patient of hers came back from the diabetic educator saying they told her an A1c of 8.0 was OK. She went berserk and was about to call the BC-ADM and tell her what an idiot she was; I let her know that that is the new recommendation for A1c in older adults."

Just curious - who/where is the recommendation that an HgA1c for older adults of 8.0 is OK?

My understanding is that tight glycemic control is less warranted for adults 70+ and that for older adults who are already diabetic that a range of > 6.0 and 8.0.

See, for example: Medscape: Medscape Access - based on this I would think that even if the pt was already diabetic, a level of 8.0 might warrant concern.

I've also read that older adults may tolerate higher blood glucose levels without adverse effects because they often have generally lower glomerular filtration rates. But my understanding still is that a healthy, non-diabetic, older adult with a life expectancy of > 10 years should be looking at a target HgA1c of

So I'm just wondering about the evidence in this case for 8.0 levels being recommended. Also, about this particular patient: were they already diabetic, particularly frail, etc.

I'm not discounting your points about EBP, which I support wholeheartedly.