December 7, 2017

From Bedside Nurse ➡️ NP Student: The Mindset

One of you amazing folks sent me an email wanting me to explain the different thought processes between a bedside nurse and a nurse practitioner student. Now, I'm not an expert or the “end all be all” of nurse practitioner students, but I will give you my opinion based on my professional experiences. In my opinion, the big difference is the level of responsibility and the extension of the clinical picture. Now, bedside nurses are and will always be fantastic people who are capable of long-term critical thinking and making appropriate clinical decisions. This post isn't a bedside nurse versus nurse practitioner column. This post is about the different goals and distinctive expectations of each practice.

As a bedside nurse, I'm presented with patients who I will care for within a 12-hour time frame. Whatever happens in that window, I'm there, and I am responsible. I check vital signs. I draw labs, I assess and reassess my patients continually, evaluating my patients' clinical conditions, while making sure I'm doing the required tasks and maintaining appropriate documentation. My job is a series of milestones and functions. I've been a nurse for over 5 years. I feel my job is performance and skill based. I'm expected to perform specific tasks and know certain skills. Everything in my nursing bubble is of independent function (i.e., activities of daily living, assessments, medication administration). Anything outside that bubble will require an order before I'm able to implement the proposed action. I'm given orders and protocols to work within, and I abide by them per my institution. For example, my patient has low urine output, and I feel after my clinical assessment, that my patient would benefit from a fluid challenge. Perhaps 500 milliliters of normal saline. As a bedside nurse, I'm not allowed to make this unilateral decision without protocols or orders in place. As a nurse, I must call or reach a provider, explain the clinical picture, any new findings, and make a recommendation. In the end, it's not up to me whether the provider takes my advice. The provider will dispense the order based on their rationales and/or theories. I'm the bedside nurse, I'm caring for critically ill patients. However, it is not within my scope of practice to change, discontinue to alter orders without prior approval. My priority is my patient's clinical condition while I'm present, while I'm performing my job. Think of it as short-term management. You're presented with problems, you communicate any changes in patient condition and work accordingly.

Now, as a nurse practitioner student, the thought process expands and deepens a bit. Let's say you get that same call from the bedside nurse. You must then ask for specific information to create your differential diagnosis list. Does this patient have a history of kidney disease? How low is the urine output? And for how long? What is the albumin level? Fluid balance results? The nurse practitioner student has additional steps and responsibilities that I, as a bedside nurse, never worried about or considered. Let's call this long-term management. When I attended my clinical rotation in the emergency department, nurses often asked for antihypertensive medication for patients. I would have to ask many questions before I had a decision. Yes, a blood pressure of 170/80 is elevated, but in a neurological crisis, hypertension is a monitor-only situation, and no medication should be administered. You must know the presenting disease process or have a list differential diagnoses. With proper clinical findings, diagnostics, and labs, you whittle the list down and go from there. It's all about proving or disproving your differentials. But the thought process is long-term in nature, and corrective measures must work within that approach. You're presented with problems and it's up to you figure out how to approach them based on the information provided. You decipher, analysis, and investigate, with the goal of making the safest choice with the given evidence.

Nursing will always be patient-centered, but the approaches vary from a bedside nurse to the nurse practitioner student. One isn't smarter than the other, and one doesn't merely boss the other around. This isn't a superior-subordinate dynamic. Both contribute, but in different aspects with varying professional aims. The role shift requires an expansive clinical viewpoint, detailed research, and comprehensive decision-making process. That is the difference between bedside nurses and nurse practitioner students, in my opinion. I've been a nurse practitioner student for four years and a bedside nurse for almost six years now.