MD vs NP in the picu setting

dyslexicandetermined · Oct 14, 2011

oh tHANKS!!!! that was good input. it really helped!

dyslexicandetermined · Oct 23, 2011

do NP in the PICU have respect?

what is it like being a NP in the PICU?

Pediatric Critical Care Columnist · Oct 23, 2011

That's an odd question. Respect from whom?

dyslexicandetermined · Oct 23, 2011

from doctors and other nures. just have talked to some people that said they were not respected as a nurse or Np.

Pediatric Critical Care Columnist · Oct 24, 2011

It'll depend on the culture of the unit. If there's a culture of respect in the workplace and everyone receives respect regardless of their position on the food chain, then of course the NP would be no different. If the culture is such that there's a definite hierarchy, with the intensivist/consultant staff at the top and the nurses, techs, RTs and ancillary staff at the bottom, maybe not. I've known of turf wars between the intensivists and the NP over who will do what, when and under what circumstances, since there's a considerable overlap in their scopes of practice. I've also known of newly-credentialed NPs having a rough ride with the nurses because of attitudinal behaviours. My unit doesn't have an NP, but we do have a Clinical Nurse Specialist (although no one is really sure what her specialty is, other than making our lives miserable). She used to be "one of us" until she was hired into this role and suddenly she became oh-so-much-better-than-us. It's quite annoying to be told that suddenly after 17 years of practice that I no longer know how to do a dressing change and will have to liaise with her so that she can come and do it for me. She behaves as if she's the only person on the unit who "gets" the parents of some of our more complex patients and she panders to the more difficult ones. It doesn't help that when she was "one of us" she wasn't particularly one of the better bedside nurses. On the other hand, I worked on a unit that had an NP, someone who had been a bedside nurse, did her Masters and then her practicum on our unit. She engaged the staff and treated them as team members from the beginning. Her partnership with the medical director in defining her role was key to her acceptance in her new role. Two very different personalities, two very different approaches and two very different outcomes.

dyslexicandetermined · Oct 25, 2011

thank you! would you say that it would be a good idea to become a NP or not?

Saija · Oct 28, 2011

Hi, I'm in my second year of nursing school and I was having a similar dilemma as you not too long ago. I had to really think about it and sort through my thoughts, because I couldn't decide if I wanted to be a nurse (and possibly one day an NP) or a doctor. What I realized was that the same reason I wanted to become a doctor in high school was the reason I want to be a nurse now. What I mean by that is that back then I didn't really know anything about what nurses actually do.

Take a look at any medical show - the doctors do EVERYTHING! If you go by those shows a single doctor could man a hospital by his/herself! From running tests in a lab, to major specialized surgery, to holding a patient's hand. Just sitting and chatting for awhile, personally delivering a patient's meds, always first on the scene when a patient crashes, etc. The nurses are in the background and rarely speak. I'm afraid that's not realistic, though. Everyone has their own job in a hospital, and the doctors do not do everything. From what I have seen and heard so far, one doctor has many, many patients, and he/she only sees each patient maybe 10 minutes a day, unless some particular procedure needs to be done. A large amount of a doctor's time is spent in an office filling out paperwork, doing research, and working on other things. In some wards I have worked in, the doctor has taken reports in the nurses' office and then left without seeing the patients at all, prescribing meds based on what the nurses are telling them alone. And just in general, I imagine it's not unlikely that many if not most doctors spend more time talking to nurses about the patients than they do talking to the patients themselves. A nurse, on the otherhand, is with his/her patients 24/7. In ICUs, I believe nurses only have 1-4 patients. In other wards it can get hectic with a few more patients, but it's never even close to the amount a doctor has.

So what do nurses really do? I’m going off the education and externships I’ve done so far, plus the stories of many nurses that I have talked to about this subject (and probably some things I've read on these forums!). A nurse is a nurturer, a teacher, a life-saver, a therapist, a counselor, a confidante, and so many other things. I’ll use the example of a nurse in a NICU (neonatal intensive care unit), only because that is a place I am very interested in working in once I graduate. A nurse has many jobs in the NICU, which include but are not limited to: monitoring the baby’s health and progress, daily checks on vitals, regular growth checks, feedings (depending on the baby’s health this could be inserting a feeding tube or it could be sitting down and having a cuddle while bottle feeding), drawing blood and other samples for testing, counseling grieving or worried parents, teaching families how to care for a such a tiny baby, facilitating a bond between mother and child (it is a nurse who gets to hand a premature baby to be held by her mother for the very first time), going to neonatal transports from other hospitals, going to the delivery or operation room in a high-risk pregnancy to help stabilize a baby that comes out not breathing or with other problems, intubating, giving chest compressions in an emergency, putting in IVs, administering medicine, maintaining medical records, giving baths, etc. In other pediatric wards a nurse can be a patient's playmate, their caretaker, the one who makes them laugh and smile and feel safe and not alone, as well as the one who provides them with medical care. And what many other nurses have told me is that many times they are the voice for a patient who cannot speak themselves, and doctors often ask the nurses what they would recommend and often take their suggestions.

The other thing I've realized about nursing is that you are the patient's first line of defense, because a doctor is very often not around. Especially with critically ill patients, a nurse has the responsibility to notice the little changes and symptoms in a patient that it takes years of experience to learn, to predict problems before they even arise, and that can be life saving. If a patient crashes, it's most likely going to be a nurse who is first on the scene, and nurses are trained to resuscitate a patient in a hospital using chest compressions, breathing tubes, intravenous adrenaline and a defibrillator. In a situation like that a doctor is of course called, but unless a doctor just happens to be there at the time, it is the nurses' quick action, professional ability and teamwork that can save a patient's life in those precious few minutes that we have before brain damage sets in. If the patient is lost, a doctor is needed to pronounce death. A nurse also needs to recognize when something is wrong with a patient based on their symptoms, they need to think critically about what sorts of illnesses could be causing those symptoms and perform the proper tests so that when they decide to take an EKG and see the patient is having a heart attack, for instance, they can tell the doctor exactly what is happening on the phone, and explain the findings on the EKG so that that doctor knows that hey, I need to get down there now! A nurse needs to recognize when a patient presents with difficulty breathing what steps he/she needs to take to find the problem, so that he/she can call the doctor in the end and say, "Hey, we have a patient with this, this this and this. We want permission to start him on CPAP, oxygen saturation is __, we think he has fluid in his lungs due to heart failure, caused by a heart attack that shows on the EKG we took." I'm sure a real nurse would be a little more eloquent, but the point is that if you think a nurse just sits back, doesn't do any thinking and waits for a doctor to give orders, you have been watching too much Grey's Anatomy and other similar medical shows. If anything, a nurse is often the first one who does the critical thinking needed to come up with potential illnesses, in order to take the right tests and know when to call the doctor and what to tell him/her. Although a nurse cannot make an official diagnosis, that doesn't mean nurses don't make diagnoses in their own minds in order to care for the patient until the doctor gets their to confirm that conclusion or to find another one.

The thing that I didn't realize back in high school was that nursing and doctoring are two completely different professions. Neither is worse or better than the other, they are just different. Nursing does mean studying a lot of medical science as well, but it's mixed with nursing science, and you become an expert in nursing. That's why you can get a phD in nursing, and for anyone who says, "Oh, you'd be in school just as long if you get a doctorate in nursing, anyway, so why not become a doctor?" That just says to me that either you are putting the value too much on money and professional respect or you don't understand how different doctoring and nursing is. Not everyone becomes a nurse just because becoming a doctor would take too long. And it doesn't take a genius to become a doctor anymore than it takes a genius to become a nurse. It just takes a lot of reading and time (which nursing does too, just doesn't take as long!). What I realized when it got right down to it was that the only reason I was still having the inkling to become a doctor instead was because 1) It would prove to people that I'm smart and accomplished and would gain me lots of respect and 2) I would have a really good salary. As far as the former goes, I realized I no longer feel the need to prove that to anyone, and that I have to choose a career based on how I enjoy the day-to-day job and not based on how much respect I would get from being a doctor and getting to make all the decisions. As for the latter, I already knew I can't choose a career based on money, because that will not make you happy.

That is why I decided to keep on the track I am on and become a nurse. And I am darn proud to be a nursing student! I'm sure sometimes people will always ask me, "Why didn't you become a doctor?" And if I can quote the link below I will tell them, "Because then I wouldn't get to be a nurse!"

You should read this: http://www.emergiblog.com/2010/02/why-dont-you-just-become-a-doctor.html

And watch this: http://nursingideas.ca/2009/02/speaking-power-to-nurses/

Now don't get me wrong here. I have the utmost respect for doctors. I don't envy their lack of time for family, especially because I don't personally want to wait to start a family until I'm 30+. But for some people they would prefer that even if they weren't in medical school, and what works for some does not work for others. Doctors should be admired because they are medical experts. But nurses should be admired too for being nursing experts. Only you can decide what is right for you, but I just got the feeling reading your posts that you might be shying away from nursing for the same reason I almost did - because you've had it in your head that you are going to be one of those highly respected and accomplished doctors like you see on TV, that every patient loves and everyone admires. And not because you actually know what a day in the life of a doctor or a nurse would actually be like.

You know when I was going through this dilemma myself I found myself reading online a lot of nurses complaining that they hate nursing. And I thought geez, is it really that bad? Am I going to turn into a bitter old nurse who wants to get out and never look back? And then, just because I was curious, I searched for people who wanted to get out of doctoring or medical school. I was thinking, surely the downsides of being a doctor are so miniscule compared to the money, respect, the challenge and joy of the job that no one could possibly regret becoming a doctor. To my surprise I found a lot. A lot of depressed doctors and medical students that wished they had never started it but after all the money (and debt) and time in school they felt trapped. It's just a matter of the grass being always greener on the other side. Everything looks rosy when you're not the one doing it. But the truth is that every job has its downsides, including doctoring and including nursing - you just have to figure out if the joy you get out of doing the good sides outweigh the downsides. Nursing is not for everyone and if you do it when your heart is not in it, you will be miserable. The same is true for being a doctor and probably just about every job out there. If you really want to be a doctor, go for it. But if your real dream is to become a nurse, be proud of it and don't let anyone ever make you doubt yourself.

What other people think of you, money, and getting to be the one "making decisions" will not make you happy. So if you pick becoming a doctor, make sure you are picking it for the right reasons. It would mean probably that you are more interested in the scientific side of medicine as opposed to the human side. In my opinion both careers contain both, but in different proportions. Although personally I am interested in both, I have found that I am more interested in the human side, which is why I chose nursing. I read something somewhere that I'll probably never forget, about why someone decided to become a nurse. It was something about how as a child she wanted to become a doctor because they fix people. Then she was hospitalized as a little girl. She was in pain and scared and the doctor came in and told the nurses what injection to give her. The nurses came in, gave her the medicine, and rocked her all night. And that is when she knew she wanted to be a nurse.

I don't know much about an NP's job compared to a nurse's, but I don't think you should get too ahead of yourself yet. If you want to be a nurse, then by all means set your goals to someday becoming an NP. BUT if you don't like the idea of being a nurse first, then you probably won't like being an NP. The way I see it, an NP has a bit more autonomy than a nurse and few more "tools in her toolbag" to help people. I see it almost like a way to be in between a nurse and an MD, with the main focus of course on nursing. Which could be perfect for someone like you or me, but not if you don't like nursing first! If the case is that nursing really does not interest you, but you aren't sure about being a doctor, then you could do research on becoming a physician's assistant. I honestly know almost nothing about the career, so you'll have to look it up yourself. But I have always thought that a nurse practitioner is still a nurse first, so don't do it if nursing is not your passion. Not only will you not be happy, but you won't be a good NP.

Pediatric Critical Care Columnist · Oct 28, 2011

What an excellent post, Saija! Thank you for your candour. You're going to be an awesome nurse. One thing I'd like to add to your second paragraph is that on our unit, the doctor writes progress notes purely based on the nursing report I give in rounds. They only touch a patient if there is absolutely no alternative so if I don't know what I'm talking about, neglect to mention some important assessment data or give a cursory report, there's a huge potential for disaster to befall that patient. I've noticed over the last couple of years that when our intensivist does evening rounds, s/he will come to my bedside and ask me if there's anything they need to know or change. They don't ask for a full report because they know that I know what I'm doing. If I say no, they move on. I could have the sickest patient on the unit, and it's not going to be any different. That's a very subtle sign of respect and I hadn't thought of it that way until just this minute.

Saija · Oct 28, 2011

Thank you! I hope so! :)

That's not only a big sign of respect, but it just goes to show how valuable a nurse's job is. It is the nurse who is there to notice when something changes, something that could be a sign of the patient taking a turn for the worst, something that demands action to prevent. Probably most doctors wouldn't even notice the subtle signs that a seasoned nurse would, even if they had the time to spend with that patient and monitor them. And not because they are somehow "worse," but just because they don't get that kind of experience on the job.

And yeah, that sounds like what I've heard from other nurses, too. A NICU nurse told me that the doctor in her ward does morning rounds (5-10 min per patient) and then even if something changes often the doctor will give out orders over the phone rather than coming down to the ward unless absolutely neccessary. Personally I want that time with the patients that the doctors don't have.

I truly believe that nurses have a really unique opportunity to really have an impact on the lives of their patients. Both medically and otherwise. You've got the time to build up a trusting relationship, and the patient may tell you things they wouldn't tell the doctor, even things that would be medically relevant. You can give them hope, comfort them when they grieve, teach them how to take care of themselves. You can make them laugh and smile when they are feeling down, and feel like they have a friend when they are lonely. I'm not saying it's not possible for a doctor to do all that, but given the time constraints much harder and for a much more brief, fleeting period of time. And another really important thing is that nurses prevent illnesses, because we study how to have a conversation with someone about their health in a way that motivates them. We tell them how to get healthy and find out what they are passionate about and show them why eating right, keeping active, etc. is so important in order to fulfill those passions. A patient's motivation to participate in his or her own care can make the biggest difference of all.

I really think being a good nurse takes a special kind of person. You have to be good with people - I've seen students and nurses who just can't talk to people, don't understand or even seem to notice a patient's feelings, and it makes it a really uncomfortable experience for all involved. I've also seen nurses who have no tact, belittle their patients and still have the nerve to call themselves a nurse. Not necessarily bad people, but just people who probably weren't right for the profession in the first place.

And something else I think we all forget to mention, is that nursing isn't just about holding someone's hand. It does take intelligence, a lot of hard work and studying, really good problem solving/critical thinking skills, a vast knowledge of medical science, the ability to predict something before it happens, act and think quickly, etc. etc. The list just goes on and on. You also have to constantly study to keep up with rapidly changing information. It seems like some people think that all nurses secretly wish they could be doctors, but they just thought they weren't smart enough or didn't feel like going through all those years of medical school. I don't understand why some people seem to think that if you are young, smart enough, have good grades and are interested in healthcare, that you should be a doctor unless you have some excuse not to. You don't need an excuse to want to be a nurse. It is not a lower profession in the same field. It's in its own field. I think we need to get some awesome nursing dramas on TV so people start to realize that a nurse's job is not somewhere in the background of the doctor, not speaking or ever doing anything worth speaking of (as medical dramas tend to show). Until then, I guess we nurses (and nursing students) have to learn to be proud of our profession and not talk ourselves down.

One of the links I posted above has a video with Suzanne Gordon. I think it was in that video that she mentioned that she watched nurses treating cancer patients, nurses who kept telling her that the doctors are the ones who cure the patients. And in her opinion, as she watched the nurses administer chemotherapy and do 90% of the job, she thinks nurses should realize that they are doing the curing, too! She always mentions how nurses introduce their profession as "just" a nurse and belittle what they do without even meaning to. It's really interesting because I realized that even though I was proud of being a nursing student before, I was doing that too! I was talking about the warm, fuzzy side of nursing and not mentioning the scientific side, the problem solving side, the part that takes intelligence and a lot of hard-studied knowledge.

I guess this subject hits close to home because it was something that was bothering me too for a little while and I had to do a lot of soul-searching before coming to the conclusion that I was meant to be a nurse from the beginning - I just didn't know it yet back when I was a teenager dreaming up what I wanted to do with my life. And I had so many people telling me, "Oh you're so young and you're smart, why don't you go to medical school?" "I would go if I was your age!" And I'm talking even my classmates who are also studying to become nurses. I'm really happy I had the dilemma though and took the time to really think it through, because now I'm more sure than ever of what I want to do. And now I can answer those friends confidently and say, "Why would I want to be a doctor when I can be a nurse!?" :heartbeat

Edit: Hey, can I ask you a quick question? I can't do any internships with kids until my third year, but this spring I'm going to have my first time in the adult ICU. I just found out that the patients there are generally sedated all the time, and I was wondering if they do that with kids, too? I'm actually in Finland so it's possible they do it differently here, but I doubt it. Right now I'm considering NICU, PICU or a different pediatric ward. I'm just really curious because part of the reason I was thinking PICU instead of NICU was because you get so much more interaction with kids that are older, but not if they are sedated..

Pediatric Critical Care Columnist · Oct 28, 2011

Are you familiar with "The Truth about Nursing"? http://www.truthaboutnursing.org/ So many of the things Saija has said reflect the same perspective. I've read Saving Lives: Why the Media's Portrayal of Nursing Puts Us All at Risk and highly recommend it, especially for students. I've also heard Suzanne Gordon speak three times and had a long conversation with her about how to explain what it is we do as nurses. Saija has done that extremely well right here. I can recommend Suzanne's book Nursing Against the Odds. I read both at work on nights when the unit was quiet. Didn't make me very popular with administration but whatever!

Patients in ICUs have to be sedated in order to keep them from extubating themselves, pulling out their central lines and other good reasons. Once they're on the road to recovery their sedation is decreased so that they breathe spontaneously, cough and move around. Sedation doesn't automatically mean that patients can't hear us, or respond to us. Intubation means they can't communicate verbally, but they can use pantomime and answer yes/no questions. Once they no longer need mechanical ventilation they're usually interactive, unless they've suffered head injuries. All PICU patients have to be at least moderately interactive before they can leave for the ward, so there is the opportunity to play, read to them, watch movies with them and all those other interpersonal interactions that we nurses are so good at.

dyslexicandetermined · Oct 28, 2011

THank you to saija and janfrn! your answers are amazing! it really put a whole new look to why i wanted to be a docter. As i was reading these post, i can see that with the personality i have and what i would like to do, becoming a nurse over a doctor i the way i am heading. i never really thought about all the paper work and less time with patients doctors deal with. i see myself helping a person more then curing the disease. The onlly reason i wanted to be a doctor was so i could beable to do more tests and also to diagnose patients. from reading your coments i can see that being a nurse, u can do alot more than i was expecting u can do. feel free to add more information on nursing if you would like....

PS. it is so true about the medical shows not showing what a true nurse is!

Saija · Oct 29, 2011

I hadn't seen that website, Janfrn, thanks for sharing! I'm going to look into those books, too (that is, when I get a chance in between school books XD)! I'm pretty new to these forums, and I found out about Suzanne Gordon on accident looking for other things online, so I had no idea if she is really well-known or not among nurses. Sounds like she is.

And thanks for answering my question. I was a little confused because I thought I'd heard people talking on these forums about playing with the kids in the PICU and all of that. It makes sense now that you explained it, though. I feel like I just want to try everything while I'm still in school or I'll never be able to decide when I get out of school. That's the other beauty of nursing, though - it's possible to switch your specialty and try something new. Though I wonder how realistic that is in real life? It must be challenging, but challenges keep life interesting, at least.

Glad to have helped, dyslexicandetermined. I hope I didn't put you off becoming a doctor, though, because as I said I believe that would be a wonderful career, as well. I just know that for me, personally, I'll enjoy nursing a lot more, so I'm a bit biased. I hope you accomplish your dreams.