Do nurses have a role in "educating" physicians in new treatments? Consider the story

RNPATL, DNP, RN · Feb 20, 2004

Roland - this information is not new and hopefully post AMI patients on a cardiac unit are receiving these medications unless they are contraindicated for one reason or another. I agree with your analogy of the nursing process and the fact that we need to advocate for our patients. I think ultimately as nurses, we do need to ensure that our patient's needs are met.

While the above statement is true, it is not within our scope of practice to make recommendations to the physician about the types of pharmacological treatments the patient should be taking. Of course, with some physicians or new docs, they may ask us what orders we would like for a patient, but it is really out of our scope to recommend medical treatment modalities for the patient. With that being said, it is certainly appropriate to bring new research to the table and have that research explored for possible patient care benefits. I would think that these types of discussions can be managed within a committee that reviews and validates the research for possible implementation with your establishment.

Over the course of the years that I have been nursing, I have seen many studies that have been published, which would have far reaching positive benefits for the patients under my care. There have been plenty of times I have discussed my research findings with our physicians. This type of dialogue with the physician eccourages a collaborative relationship and also lets the physician know that your practice is research based. Some physicians respect your commitment to exploring research and some do not. Regardless of the what the physician thinks, it is always good to be aware of research, both medical and nursing.

Several years ago, I encouraged our hospital to develop a research committee that reviewed research on several patient care related topics. I was pleased when this committee really took off. Our Medical Services Committee was very involved with the review and validation of research at our hospital and worked very closely with nursing administration and our physicians to ensure that research related practice was a big part of our overall care philosophy.

To this end, it is important for nurses to advocate for their patients and bring current research findings to light in their respective clinical areas. It is also very important to discuss this research with your physicians. As nurses, our ability to advocate for our patients and ensure that they receive care that is validated by research is very important. Our methods of communicating these findings can be just as important and requires us to bring this information to light in a manner which provokes action by nursing leadership.

JMHO. Patrick

nurseT · Feb 20, 2004

Nurses do not recomend out of their scope of practice. We need to understand that we may learn many things being so closley involved with pt care, but we only have the bare bones compared to what physicians have to know. There have been many occasions where a physician has asked me what my opinion was on a hospice pt and pain tx simply because he was in unfamiliar territory and I had knowledge. I did handle it with respect by stateing protocols and faxing copies of same to physician. There have been other times I have had consults with the pharmacist first and then made recomendations " per pharmacist " and asked pharmacist if it was ok first and give pharmacist opportunity to make the call himself if he wasn't busy. I don't know how many times I have had a CNA try to be a nurse by telling me what a pt needs and that is truly out of her area and extremely irritating.

Roland · Feb 20, 2004

I am not saying that nurses should have the power to alter a patients treatment outside of their scope of practice. However, I AM saying that there should be "formal" channels in which research, and possibly helpful information can be "made available" to physicians. Consider for instance that the ABOVE information HAS been known for quite awhile and STILL is not utilized by most physicians to the fullest extent (despite being the reccomendation of the American Cardiology Association as stated in the article). I would submit that patients are dying, because information like this IS NOT implemented as soon as it should be under optimal circumstances.

Ironically, my "nurse advisor/input process" might create "pressure" on physicians to better implement the advice of their own organizations! Consider, that at the very least it would create a permanent "record" of "input" by nurses relative to their facility. IF physicians choose not to consider such input they may be creating the foundation for more aggressive malpractice litigation at their facility (an attorney might be able to establish for instance that nurses at a given facility had long brought the above information to the attention of physicians who failed to act upon or even consider the information.). I have long believed that nurses as a profession should be willing to work with attorneys (where appropriate) to bring "pressure" on health care organizations to do the right thing. It can be a BIG hammer and nurses should be willing to utilize it when appropriate. To do less is to fail to be a complete patient advocate and to abandon an important role in the patient care "optimization" process.

Can any of you think of specific examples where nurses "knew" things that could have positively impacted patient care, had their insite been considered? Let me provide one example: At the hospice facility where my mother was taken virtually every patient was placed on Haldol (I know this because I "spoke with" virtually every nurse in the facility during the two weeks she was there). Many of the nurses privately admitted to me that they thought that this amounted to the mass use of "chemical restraints" to lighten the work load on the facility, however they said that it was "the doctor's decision and she really likes Haldol". I called other similar facilities and almost NONE used Haldol (or at least admitted to using) in this manner. Now, THIS would be an example of a situation where were I a nurse that I would use the "built in advisory process" that I am proposing to bring the excessive utilization of Haldol to the attention of the Dr. I have worked at companies where EVERY suggestion receives a responce by upper management. If they didn't like a suggestion or couldn't implement it you still received a reply and generally a specific reason why it couldn't, or wouldn't be implemented.

Much organizational research and experience has time and again confirmed the notion that those "closest to the job being done" often have input that is as or MORE useful than even what the "experts" in "management" can provide. From tragedies such as the Space Shuttle disastors to corporate injustices such as Enron, retrospective analysis has revealed that HAD MANAGEMENT (in this case Dr's and hospital administration) more closely listened to the input of others that major, negative outcomes could have been avoided.

CoffeeRTC, BSN, RN · Feb 20, 2004

Nurses do not recomend out of their scope of practice. We need to understand that we may learn many things being so closley involved with pt care, but we only have the bare bones compared to what physicians have to know. There have been many occasions where a physician has asked me what my opinion was on a hospice pt and pain tx simply because he was in unfamiliar territory and I had knowledge. I did handle it with respect by stateing protocols and faxing copies of same to physician. There have been other times I have had consults with the pharmacist first and then made recomendations " per pharmacist " and asked pharmacist if it was ok first and give pharmacist opportunity to make the call himself if he wasn't busy. I don't know how many times I have had a CNA try to be a nurse by telling me what a pt needs and that is truly out of her area and extremely irritating.

I agree with this... working in LTC and knowing the pts better than the docs, many of them ask "Whats worked before...What does doc so and so say..." or even "What do you think..What's the pharmacist say.." By no means am I writing an order myself...but sometimes the docs need alittle help or imput so that they can make an informed decision.... Hospice pts and pain control is still not undersood by many of our docs..Another problem is that some docs don't know geriatric pharmacology and often order extremely inappropriate doses or drugs for them... in the end..they are the doctor, I'm the nurse..

RNPATL, DNP, RN · Feb 20, 2004

Roland - the long and the short of it is that there are physicians that are great and do wonderful things for their patients. These physicians stay on top of research and work hard to ensure the medical care they provide for their patients is the best it can be. Conversely, there are physicians that could really care less about research and will conduct their practice exactly as they please.

Case in point .... I use to work with a physician that used the old three bottle chest tube system. This system is so old that they do not even make parts for the main suction any longer. I reviewed several different studies and research projects and brought the recommendations of these studies to the attention of this physician and encouraged him to change his practice and begin using the self contained units (in this case it was the PleuroVac System). He refused, stating that he was accustome to working with this system and saw no reason to change. Forget that the research I showed him revealed decreased risks of pneumo and better patient outcomes .... he refused ... end of discussion.

This issue has been a professional and life long issue for most nurses. Physicians do as they please and they probably always will. Is this acceptable? Hell NO! But is it reality? Hell YES! You are right, as nurses, we must continue to advocate for our patients and ensure they get what they need to be well. However, we do not and can not control the practice of a physician. Sure, we can bring in the attorney, case law and many other strong arm ways to provoke the physician to change. When it comes right down to it, the patient has the choice and can and should change physicians if they believe that their care and treatment are not up to date to modern standards and research.

Many people may ask, "well how does the patient know if he/she is getting the most up to date care?" This is where patients need to be in control of their own destiny and get second opinions and remember that their physician is not the end all, be all. I know from personal experience, I have had to call the shots for my care. I was not taking ceratin medications that I knew I should be taking. I approached my physician, who took a real lazy attitude with me (you know the ones ... oh he is a nurse and he is going to tell ME how to care for him). I finally went to another physician and was properly taken care of.

As nurses, we can not change a physician's practice. That is what it all boils down too. :)

EastCoast · Feb 20, 2004

I can give an example of nursing promoting standards or whatever you want to call it.

The patient i admitted with an MI was on ARB (type of ace inhibitor) prior to and during her stay. Today i got a note in the progress notes written (not a post it...it was legally written) that said the following..."dear dr. (no...they still can't figure out how to write dear NP!). could you please document in the chart why your patient is not on an ACE post MI?".

Well the long side is it made me double check my orders to make sure. The odd thing is is that the nursing coordinator (discharge planner) didn't know that an ARB was akin /similar and accceptable to an ACE. However, the question is: why was there a note? It came down to something about JCAHO standards and recommendations or some such nonense that would keep our hospital looking good. When i told them that the patient was on a ARB they told me that JCAHO didn't consider that to be okay (probably b/c of cost). So i told the coordinator that the patient was on an ARB b/c we could easily sample the med as opposed to ace which is not as readily available and the patient couldn't afford her meds. I had to document that in the chart.

Regarding promoting standards or suggesting treatments? As a former bedside RN I would welcome another nurse putting something in the chart asking me or suggesting something. While I may have a reason to follow along that recommendation or not it will still provide food for thought and give me an opporunity to think differently.

gwenith, BSN, RN · Feb 21, 2004

Using a big stick is never the way to effect change - it just makes the donkey more stubborn. It is better to dangle a carrot.

So what carrot can we dangle to get the change to happen. Here we are moving towards "evidence based pratice" and whole hospitals have become EBP centres. EBP is where you use recommendations from systematic review centres such as the Cochrane Database for medicine and the Joanna Briggs Institute for nursing. Systematic reviews make sense of the plethora of research on a subject, discount any product bias and identify future avenues for research.

To be honest once I started looking at the JBI's reviews I realised that much of nursing needs to look to itself first and get our own practice right and validated before we heap too much trenchant criticism on others. A bedsore can kill just as effectively as missing one med from the list.

Roland · Feb 21, 2004

Let me be more specific about how such a system might work. Let's say you were a CT/ICU nurse and you noticed that few of your post MI patients were on anything approaching the above drug combination (maybe you noticed they were getting aspirin, and beta's, but no statins or ACE inhibitors). You would "file" the above article with any relevent personal observations and any additional medical references to support your observations. Once "filed" the reccomendation would go to some sort of "coordinator" who would probably be an MD or NP, their job would be to determine if your advice had even the "slightest" merit (was it essentially scientific with some clinically based evidence to support your thesis). If it met this minimal criteria it would be presented to the head resident of the appropriate unit for consideration at a weekly or monthly meeting (along with other such reccomendations). There it would be discussed and evaluated. In any case it would become a "permanent record" that could be reviewed in the future. Let's say that someone brings litigation because their mother died post MI. Their attorney could present the fact that their were numerous reccomendations on file that this protocol be implemented. This is just one "sample" model that I am sure could be vastly improved upon, just a "starting point". Keep in mind that the above article is nothing more than the EXISTING guidelines published by the American College of Cardiology AND the American Heart Association (the STORY is that despite this being the case this drug combination is STILL seldom utilized in spite of overwhelming evidence supporting its efficacy.) How can nurses be the best possible patient advocates if they ignore this kind of thing?

RNPATL, DNP, RN · Feb 21, 2004

Using a big stick is never the way to effect change - it just makes the donkey more stubborn. It is better to dangle a carrot.
So what carrot can we dangle to get the change to happen. Here we are moving towards "evidence based pratice" and whole hospitals have become EBP centres. EBP is where you use recommendations from systematic review centres such as the Cochrane Database for medicine and the Joanna Briggs Institute for nursing. Systematic reviews make sense of the plethora of research on a subject, discount any product bias and identify future avenues for research.
To be honest once I started looking at the JBI's reviews I realised that much of nursing needs to look to itself first and get our own practice right and validated before we heap too much trenchant criticism on others. A bedsore can kill just as effectively as missing one med from the list.

Bravo to your hospital for this type of philosophy! Wonderful to hear, I wish my hospital was doing something like this. :uhoh21:

gwenith, BSN, RN · Feb 21, 2004

Roland - you are still advocating a system running by negative feedback whereas an EBP system runs by positive input. We are finding out here the real cost of litigation and our approach is to cut out the lawyers as much as possible by having good systems in place in the first place.

This sounds like a nice system but there are at least 3 major flaws which will prevent implimentation.

1) Who decides?? Research outcomes even when systematically reviewed are not cut and dried

2)Pt individuality - you might decide that the pt should be on beta blockers but the pt might be asthmatic - conraindicated!!! OR and I have seen this the cardiologist choose not to prescribe because the patient is known to be non-compliant in the extreme and will ignore tablets for days only to take 5 at once - not good with Beta blockers - and this was a Pt we had TRIED to educate

3) Cost - your system is costly

4) You are assuming the nurse IS as knowledgable as the MO what if the latest research proves what is now suspected - that statins can interfere with memory - it is still a recommendation by the heart association but MO are now reluctant to prescribe because it becomes a matter of which system is most important - mind or heart??? Comes back to the saying - if you want entertainment watch a neurosurgeon and a cardiologist argue over a patients' BP

Roland · Feb 21, 2004

There is evidence to indicate that many of the complications from long term statin therapy can be ameliorated by the concurrent administration of coenzyme Q-10 (available OTC see references below about coenzyme Q10). In addition, there is mounting scientific evidence that alpha lipoic acid in combination with acetyl-l-carnitine can have a powerful effect in counteracting non dementia related memory loss. Of course there will always be situations where a particular drug is not appropriate for a given patient. However, my scenario goes to a situation where the four drug combination is CONSISTENTLY not being utilized (as the study indicates that it is not).

While I don't believe nurses to be nearly as knowledable as M.D.'s it doesn't change the fact that they often have valuble, relevent, input that can be germaine to optimal patient care and outcomes. My concern is that currently there exists no formal system by which nurses can consistently share this input (indeed, nursing schools do not often stress the role of nurses as "guardians of patient care"). My approach to emphasizing a permanent record that might aid future litigation exists because I believe it to be the ONLY way that M.D.'s and administration will be persuaded to consistently consider such input (there must be a potential monetary cost to NOT doing so or a potential economic benefit for DOING so).

My model emphasizes an interconnected, integrated "health care team" where each segment nurses, doctors, and allied health care personnel act as a "check and balence" upon the other with the goal of providing the best patient care possible. I believe that this can only occur in an environment with recognized, formal channels of communication for the exchange of pertinent information. I would be willing to consider other mechanisms that might accomplish the same objective.

Coenzyme Q-10 References (note references 1, 22, and 23 are especially relevent)

1. Ellis CJ, Scott R. Statins and coenzyme Q10. Lancet. 2003 Mar 29;361(9363):1134-5.

2. Singh RB, Neki NS, Kartikey K, et al. Effect of coenzyme Q10 on risk of athero- sclerosis in patients with recent myocardial infarction. Mol Cell Biochem. 2003 Apr;246(1-2):75-82.

3. Ohmoto N, Fujiwara Y, Kibira S, Kobayashi M, Saito T, Miura M. Cardiomyopathy showing progression from diffuse left ventricular hypertrophy to dilated phase associated with mitochondrial DNA point mutation A3243G: A case report. J Cardiol. 2003 Jan;41(1):21-7.

4. Fosslien E. Review: Mitochondrial medicine--cardiomyopathy caused by defective oxidative phosphorylation. Ann Clin Lab Sci. 2003 Fall;33(4):371-95.

5. Engelsen J, Nielsen JD, Hansen KF. Effect of coenzyme Q10 and ginkgo biloba on war- farin dosage in patients on long-term war- farin treatment. A randomized, double- blind, placebo-controlled cross-over trial. Ugeskr Laeger. 2003 Apr 28;165(18):1868-71.

6. Singh RB, Kartik C, Otsuka K, Pella D, Pella J. Brain-heart connection and the risk of heart attack. Biomed Pharmacother. 2002;56 Suppl 2:257s-265s.

7. Sarter B. Coenzyme Q10 and cardiovascu- lar disease: a review. J Cardiovasc Nurs. 2002 Jul;16(4):9-20.

8. Piotrowska D, Dlugosz A, Pajak J. Antioxidative properties of coenzyme Q10 and vitamin E in exposure to xylene and gasoline and their mixture with methanol. Acta Pol Pharm. 2002 Nov-Dec;59(6):427-32.

9. Tran MT, Mitchell TM, Kennedy DT, Giles JT. Role of coenzyme Q10 in chronic heart failure, angina, and hypertension. Pharmacotherapy. 2001 Jul;21(7):797-806.

10. Shults CW, Oakes D, Kieburtz K, et al. Effects of coenzyme Q10 in early Parkinson disease: evidence of slowing of the function al decline. Arch Neurol. 2002 Oct;59(10):1541-50.

11. Kishimoto C, Tomioka N, Nakayama Y, Miyamoto M. Anti-oxidant effects of coen- zyme Q10 on experimental viral myocarditis in mice. J Cardiovasc Pharmacol. 2003 Nov;42(5):588-92.

12. Sandhu JK, Pandey S, Ribecco-Lutkiewicz M, et al. Molecular mechanisms of gluta- mate neurotoxicity in mixed cultures of NT2-derived neurons and astrocytes: pro- tective effects of coenzyme Q10. J Neurosci Res. 2003 Jun 15;72(6):691-703.

13. Chuang YC, Chan JY, Chang AY, et al. Neuroprotective effects of coenzyme Q10 at rostral ventrolateral medulla against fatality during experimental endotoxemia in the rat. Shock. 2003 May;19(5):427-32.

14. Shults CW. Coenzyme Q10 in neurodegen- erative diseases. Curr Med Chem. 2003 Oct;10(19):1917-21.

15. Kishimoto C, Tamaki S, Matsumori A, Tomioka N, Kawai C. The protection of coenzyme Q10 against experimental viral myocarditis in mice. Jpn Circ J. 1984 Dec;48(12):1358-61.

16. Lamperti C, Naini A, Hirano M, et al. Cerebellar ataxia and coenzyme Q10 defi- ciency. Neurology. 2003 Apr 8;60(7):1206-8.

17. Langsjoen PH, Langsjoen A, Willis R, Folkers K. Treatment of hypertrophic car- diomyopathy with coenzyme Q10. Mol Aspects Med. 1997;18 Suppl:S145-51.

18. Langsjoen P, Langsjoen P, Willis R, Folkers K. Treatment of essential hypertension with coenzyme Q10. Mol Aspects Med. 1994;15 Suppl:S265-72.

19. Langsjoen H, Langsjoen P, Langsjoen P, Willis R, Folkers K. Usefulness of coen- zyme Q10 in clinical cardiology: a long-term study. Mol Aspects Med. 1994;15 Suppl:s165-75.

20. Langsjoen PH, Langsjoen PH, Folkers K. Isolated diastolic dysfunction of the myocardium and its response to CoQ10 treatment. Clin Investig. 1993;71(8 Suppl):S140-4.

21. Folkers K, Langsjoen P, Langsjoen PH. Therapy with coenzyme Q10 of patients in heart failure who are eligible or ineligible for a transplant. Biochem Biophys Res Commun. 1992 Jan 15;182(1):247-53.

22. Folkers K, Langsjoen P, Willis R, et al. Lovastatin decreases coenzyme Q levels in humans. Proc Natl Acad Sci U S A. 1990 Nov;87(22):8931-4.

23. Langsjoen PH, Langsjoen PH, Folkers K. A six-year clinical study of therapy of car- diomyopathy with coenzyme Q10. Int J Tissue React. 1990;12(3):169-71