Dr Crippen has strong views on the role of senior nursing staff in specialist areas. His views are widely shared. In fairness, there are also folk who have opposite views. I'm not opening up the Nurse Consultant/Specialist role is good/bad here, I'm wanting to touch on just one specific area . . . diagnosis.
I couldn't do my job the way I do without my senior nurse colleagues who are the most important members of the team. What they do, they do exceptionally well and do expediently. Patients and GPs love 'em, and rightly so.
What nursing staff are weaker at is diagnosis. Diagnosing things that are the bread and butter of a speciality is fairly straight forward. Diagnosing the obscure is harder. Diagnosing the exception that looks commonplace, presenting largely with commonplace symptoms, is exceptionally tricky.
I used to believe that only medics could robustly diagnose problems. I've changed my view. Nursing Staff can diagnose common problems effectively, most of the time. They can not diagnose atypical and obscure problems and should not be expected to do so since they've not had the training to do so.
The endless and involved teaching of anatomical structures, physiological function, pathological processes and outcomes from this necessitated years at medical school that nurse training rightly does not include.
The training process means a doctor may not know exactly what the condition he's looking at is, but can make sensible considerations of anatomy, physiology and pathological processes on these to ellucidate causes and generate diagnostic formulations. Nurse training precludes this process.
Worse, there's an implict and explicit acceptance amongst many senior nursing staff that getting it right enough of the time is good enough, so missing the odd wrong diagnosis isn't something to fret over. This was brought home when senior G and H grade nurses (erm, band 7 and band 8 in new speak) have undertaken the nurse prescribing courses over the last couple years. I've mentored many nurses (and physios) through this and been staggered by the attitude of the course lecturers and course organisers. Just one example. When talking through managing an unwell child with fever and sore throat there was anxiety from (these very senior) nurses over missing meningitis and what should be done to address this. They were told that nurse prescribers need to be confident in managing what's common, viral infection and bacterial throat infection would account for almost all presentations so manage the child as that. But what if it is meningitis, they persisted. Their lecturer explained that meningitis is so rare, viral/bacterial infection so common, if they worry about meningitis they'll be referring everything and never treating anything so it's best to ignore the rare diagnosis of meningitis altogether and focus on treating what it's almost certainly going to be.
I've worked in paediatrics. I saw children with proven meningitis. I've trained and worked in General Practice. When I worked in A&E I saw a child with meningitis who died.
Meningitis is not common. But it is present. To ignore it as a diagnostic possibility is madness. But it is what Practice Nurses, A&E Nurses, District Nurses and ward staff (all at the most senior level) have been told to do. They were not told this in "the bad old days" they were directed to do it this year. Let us hope none ever treat my children.
Diagnostic formulation is based on the probability of Diagnosis X accounting for the problems your patient's presenting with. Always listing obscure causes for a patient's common problem and referring on to exclude these is not helpful. The opposite, of only considering common causes, is equally unhelpful (yet it is what most nurses are being asked to do).
For nursing staff to be asked to do more than triage, to ask them to start to diagnose, is fraught with problems since it is manifestly outwith their training. They can be excellent at assessing what's common but I really believe that ignoring (knowingly or unknowingly) the uncommon and rare conditions is a grave disservice to our patients.
It is neither how I would wish to treat patients nor how I would want my nearest and dearest treated.
My nurses are exceptional at what they do. But let's not collude with managers and the Department of Health that cheaper nursing staff gives better outcomes. It gives decent outcomes for most patients most of the time. It gives disastrous outcomes for others.