But research shows that patients are at least as satisfied, and in many cases more so, with the care they received from a nurse practitioner than from their GP. Nurses score better on communication and make better and more complete records in many cases than their medical colleagues. In a paper published in the BMJ, researchers from the department of Primary care at the University of Bristol, led by Dr Chris Salisbury, wrote:
“Nurse practitioners seemed to provide a quality of care that is at least as good, and in some ways better, than doctors.”
Extended roles for nurses and other health care professionals are here to stay, the need to reduce the hours worked by Junior doctors while freeing other doctors up to concentrate on more pressing matters is now becoming increasingly common practice around the UK (here). However much Dr Crippen would like it to be so, Nurses are not going to be confined to the sluice washing bedpans while Doctors are the ones making all the difficult decisions out on the ward.
But what of the charge that not being medically trained, Nurses do not know what we don’t know does this statement in its general sense not apply equally to Doctors as to any other health care professionals? Well perhaps not if the conclusions of a paper published in the journal of Personality and Social Psychology in 1999 entitled “Unskilled and Unaware of it: How difficulties in Recognising One’s own incompetence leads to inflated self assessment” are anything to go by. Following a number of experiments in which subjects of varying expertise were asked to rate their ability at various tasks against their actual performance at those tasks the researchers concluded.
“People tend to hold overly favourable views of their abilities in many social and intellectual domains. The authors suggest that this overestimation occurs, in part, because people who are unskilled in these domains suffer a dual burden. Not only do these people reach erroneous conclusions and make unfortunate choices, but their incompetence robs them of the ability to recognize it. Across four studies, the authors found that participants scoring in the bottom quartile on tests of humour, grammar, and logic grossly overestimated their test performance and ability. Several analyses linked this overestimation to deficits in their ability to distinguish accuracy from error.”
A puzzling aspect of the results was that those deemed incompetent at a task fail through experience to learn that they are unskilled at that task. One explanation for this finding is that people rarely receive negative feedback on their performance in every day life, and when they do those considered psychologically healthy are more likely to attribute their failure to circumstances beyond their control rather than to any failing within themselves. Perversely those considered to be psychologically unhealthy are more likely to have a realistic estimate of their performance and ability than those considered psychologically more robust.
The tendency to overestimate our ability in a profession is most noticeable when the profession relies on a degree of expert knowledge. In such professions (such as medicine) a lack of knowledge implies not only the inability to perform competently but also the inability to recognize this fact. In other professions which require expert knowledge and a physical skill or ability people are far less likely to overestimate their ability. Art critics may posses an encyclopaedic knowledge of art but will readily admit to being unable to paint to save their lives and few of us would be prepared to go three rounds with Mike Tyson despite an encyclopaedic knowledge of the theory and rules of boxing. In these professions knowledge about a skill does not translate into a belief of competence in that skill.
The authors conclude by that in order for the incompetent to overestimate themselves they must satisfy a minimal threshold of knowledge that suggests to them that they are competent at the task they have been asked to perform and the more complex the task the more an incompetent practitioner is likely to overestimate their ability. (Kruger, J & Dunning, D 1999). Clearly education and training is the answer. Improving the skill of Nurse practitioners will not only make them more competent at what they do but will make them better able to recognize the extent of their knowledge and help them recognize the limitations of their abilities. As Miller (1993) is quoted as saying
“It is one of the essential features of such ignorance that the person so inflicted is incapable of knowing that he is incompetent. To have such knowledge would already be to remedy a good portion of the offence.”
Miller, W I (1993) Humuliation, Ithaca, NY Cornell University Press.
Tags: nursing, professionalism
12 comments
July 9, 2008 at 8:14 pm
Pingback from Mental Nurse / Extended Roles vs Expanded Roles
April 2, 2008 at 3:52 pm
DrJCrippen
Hi there E
Great post.
Of course, once must never take hyperbole TOO seriously - or Dean Swift really would have eaten the children - but I do of course perpetrate all the crimes of which you accuse me, and many more.
Nurses “Don’t know what they don’t know” and using this as an argument against extended roles for nurses and other health care professionals.
Not just nurses. ANYONE put into roles for which they are not properly trained - GPwSIs being another classic example.
Research has show that patients are happier with care from and NP than from a doctor. Possibly, but then who are they to judge. Polls in Zimbabwe have shown overwhelming support for Mr Mugawbe for years. And of course, the air hostess is much nicer and chattier than that grumpy old pilot. Much of the research you quote is from tossers with beards who set out assuming that which they are pretending to prove.
Extended roles for nurses and other health care professionals are here to stay, the need to reduce the hours worked by Junior doctors while freeing other doctors up to concentrate on more pressing matters is now becoming increasingly common practice around the UK
And that is, in a nutshell, what is destroying the NHS. Releiving junior doctors of experience whilst people with lesser training and, by and large, lesser intellectual capacity do the jobs in an adquate, mechaistic fashion. Penny wise, pound foolish. I know you won’t like that, but it’s true.
The rest of you post is much more interesting, in terms of discussing awareness of boundaries of knowledge.
The authors conclude by that in order for the incompetent to overestimate themselves they must satisfy a minimal threshold of knowledge that suggests to them that they are competent at the task they have been asked to perform and the more complex the task the more an incompetent practitioner is likely to overestimate their ability. (Kruger, J & Dunning, D 1999). Clearly education and training is the answer. Improving the skill of Nurse practitioners will not only make them more competent at what they do but will make them better able to recognize the extent of their knowledge and help them recognize the limitations of their abilities. As Miller (1993) is quoted as saying
“It is one of the essential features of such ignorance that the person so inflicted is incapable of knowing that he is incompetent. To have such knowledge would already be to remedy a good portion of the offence.”
That is fascinating, and raises all sorts of issues. And no, I don’t think that nurses have a monopoly of boundary incompetence.
But, of two facts I am certain.
Jobs that have always traditionally been done by doctors and being handed down to nurses; jobs that have traditionally been done by nurses are being handed down to auxiliaries. In the opposite direction, it is called the “skills escalator”
The health service IS dumbing down on the front end. And however much you hate it, the fact of the matter is that someone with 10 A* at GCSE, 4 grade A A levels, an honours degree from Oxford and ten years training there after brings a better skill set to the NHS than someone who has 5 GCSEs and a nursing qualification. Those are, admittedly extremes, but it makes the point. Nurses are cheaper and quicker to train than doctors. Yes, you can train them up to do endoscopies, or whatever, but they are still not doctors.
I am sure of one thing, though. You will “win”. The nurses will take over much of the “free at the point of entry NHS” and they will all clutch on to their little precious piece of the jigsaw trouble.
This is the death knell of the traditional medical profession. I hate that, and rail against it. You think it is a good idea, and you are entitled so to do. What I want to ensure through NNHS BLOG DOCTOR is that the public understands what is going on, And they do not at the moment.
John
April 2, 2008 at 4:01 pm
TheShrink
I’m all for this New Ways of Working malarky, with nurses doing well what nurses can do well.
““Nurse practitioners seemed to provide a quality of care that is at least as good, and in some ways better, than doctors.””
I’d agree with this, largely. Most of the time my patients get a better deal from follow up visits by CPNs than from a follow up out-patient clinic appointment with me.
There one area in mental health (especially mental health services for older adults) that I believe doctors have a niche that nurses and PAMs lack, and that’s diagnosis. We’re better at therapeutics (but nurse prescribers are pretty sound at what they do) because we’re trained to be, but diagnosis really is the only thing we do that nurses can’t. Nurses are fantastic at triage (is there mental illness, yes/no). Nurses are fantastic at surveillance (are there risks to self, property or others yes/no). Nurses are fantastic at monitoring (is there improvement, yes/no). Nurses are fantastic at supporting my patients through having the resources (time and training) to help them in many areas far better than I can.
1 in 12 cases of dementia are reversible. We have dementia nurses from band 6 to band 8 and a review I did found that the number of patients seen by nusring staff with a formulation of something other than dementia (or mood disorder impacting on cognition) over the last two and a half years : 0
This is in a specialist memory service with experienced nurse prescribers who have huge expertise in dementia care.
Problems such as metabolic disorders, hydrocephalus, neoplasia that I found, they hadn’t. And why should they? I trained as a medic then as a GP then as an old age psychiatrist so am trained to find physical health problems that can be treated/cured rather than presuming they have dementia and generating palliative care, only.
Roles can change, according to skills. In these discussions I’m all for nurses having expanded roles as long as there’s fidelity to nursing skills aquired. Our nurses don’t want doctor’s roles but do want expanded roles, thus I’m happy. Pushing someone into a role beyond their remit, for an experienced nurse, will mean they perform well enough most of the time (since they’re experienced sensible souls) but there will be situations when they’re out of their competencies (and may or may not appreciate this).
Having doctors do everything is a bad thing. Having nurses do everything is a bad thing. Fidelity to what skills/competencies folk have, not their role, is a good thing.
April 2, 2008 at 6:21 pm
zarathustra
Interesting comments Shrink, and I’m broadly in agreement with pretty much all of your views there.
I’m actually started to head in the direction of an extended nurse role myself, as I’m currently undertaking post-registration training in child psychotherapy.
As for nurse prescribing, I don’t really see much of a role for it in CAMHS as so much of the medications in child psychiatry are being prescribed off-licence, and to do that requires a doctor.
Diagnostics - I’d say that should remain the overall responsibility of a child psychiatrist, although I’m happy to contribute data to the diagnostic process (e.g. by carrying out school observations of children suspected of having ADHD).
April 2, 2008 at 6:27 pm
E
I am not trying to win as you put it.
“The fact of the matter is that someone with 10 A* at GCSE, 4 grade A, A levels, an honors degree from Oxford and ten years training there after brings a better skill set to the NHS than someone who has 5 GCSEs and a nursing qualification.
I wouldn’t necessarily disagree with you, but I guess it would depend on the task at hand as to who had the more appropriate skill set. But equally I don’t see the point of using someone with the skill set you describe to do a task that can be done by someone with 5 GCSE’s and nursing qualification plus whatever extra training they require to do the job safely. Sledgehammers and walnuts spring to mind. Perhaps the answer to ensure safe practice and prevent NPs going off pieste as you put it are, dare I say it, well written, clear and explicit protocols. Oh and access to someone who might know more about it than you do. I wonder who that could be, white coat, stethoscope, name escapes me what are they called.
I am with the shrink on this
Roles can change, according to skills. In these discussions I’m all for nurses having expanded roles as long as there’s fidelity to nursing skills acquired. Our nurses don’t want doctor’s roles but do want expanded roles, thus I’m happy. Pushing someone into a role beyond their remit, for an experienced nurse, will mean they perform well enough most of the time (since they’re experienced sensible souls) but there will be situations when they’re out of their competencies (and may or may not appreciate this).
April 3, 2008 at 9:11 am
beakie
Very interesting post, E, thanks for that.
I’m afraid I’m going to come down here somewhat on the side of the good Dr C. I find it extremely disappointing that nurses are so fed up with the actual core business of nursing that they are hoovering up the crumbs from the doctors’ table and giving themselves fancy titles about which there is little clarity and even less standardisation.
I’m sure patient satisfaction surveys paint a pretty picture because that is what patient satisfaction surveys tend to do. They ask questions which elicit satisfied responses. We all know the problems with these sorts of surveys - poor response rates, the more ‘conformist’ people tend to respond, their responses are influenced by what they think those conducting the survey want to hear. It is far more honest and informative to look at complaints.
Extending your role is different to expanding your role, in my view. Extending your role is taking a key element of nursing and enhancing your ability to do that. Zarathustra’s psychotherapy course would be an example of extending his role (and please, Z, do keep us informed about what you get up to on that course; I’d be interested to know).
Expanding your role, on the other hand, suggests taking on things that are extra to your key nursing skills - prescribing, diagnosing, minor surgery and so on. I’m not in favour of that at all. I agree that this leads to a dumbing down of the service, not because nurses are dumb but because by the very nature of the education they receive for these expanded roles, they are at risk of focussing on their discrete area of practice and are not in a position to take the ‘helicopter view’ that five years basic medical training plus a number of years further education in your specialisation would offer you. That’s poorly expressed, but I hope you get the gist of what I’m saying.
April 3, 2008 at 10:43 am
E
Patient satisfaction surveys are of limited use in planning a health service but should not be dismissed entirely IF and that is a big if they are well constructed they can yield useful information about what patients want and to a certain extent what works.
An extended role rather than expanded role, yes that captures my position exactly. How about it Dr C can we agree that extended roles for nurses with appropriate extra training is a good idea? All we have to do now is agree what is an extended role as apposed to an expanded role.
April 3, 2008 at 6:39 pm
beakie
Hmm - I’d have to disagree with that. Being popular isn’t the same as being good at what you do - the fact that Jeffrey Archer’s novels sell in their millions shows that most clearly.
April 3, 2008 at 6:40 pm
beakie
I meant there that I’d have to disagree with your comments about satisfaction surveys.
April 3, 2008 at 7:13 pm
mystic mog
Fair point about satisfaction surveys however on the more general topic of roles v training i think Dr C is missing the point. Yes all those years of academic effort and medical training have meaning, yes in some ways these skills couldnt be safely replicated by other less highly trained staff however there are many areas in the NHS which wouldnt run half as well as they do without specialist nurses. To moan that this is dumbing down fails to deal with the realities of today. We arent going to return to junior doctors working 70 plus hours a week, valuable experience or not. There will be an ongoing increase in Nursing roles, time to focus on improving this process for everyone, not moaning that doctors arent at the centre the way they once were
April 5, 2008 at 9:15 am
E
This might be splitting hairs but the research mentioned the satisfaction expressed by patients with the level of their care it didn’t say the level of satisfaction was measured with a “satifaction survey” there are others ways of measuring satisfaction other than through surveys. But even if the qaulity of care was (and it probably was) measured at least in part using a survey of some sort, provided the survey was properly constructed and carried out it can still yield usful information about the quality of care provided.
April 6, 2008 at 2:34 pm
Mr Ian
Splitting hairs may be just where the balance lies. Not in the Pt Sat survey… I mean in the extended role and just how far?
Shrink is very right that the limitations of a clinical nurse specialist in one area do not force them to think outside the box sometimes (unskillled and unaware per se). Shrink’s box is so much bigger than mine (ooo-eerr) that I respect the beneficence of skilled practitioner - but are all psychs as experienced as Shrink?
I am just about rancid in the head with fraudulent labels of ’schizoaffective disorder’ being applied to anyone who has a NOS-able condition. It’s total cock and is only ever employed to justify scripting neuroleptics. Usually Clozapine. With no clinical justification.
I have utmost respect for those medics who act ethically and sensibly. Not everyone referred to them is a mental case. Not every behaviour is reduced to neurological dysfunction, amendable by an ever increasing titration of psychotrophic [sic] medications. This is why I enjoy reading the likes of Shrink who says “I can’t give you a pill to make you happy” when so many medics are more than keen to seemingly justify their medical titles by prescribing medicine willy-nilly.
I support nurses specialising/extending as an advancement against bad doctoring; but not so far as to say they need to prescribe - tho I would love to be able to apply more ‘ethics’ to the current (generally speaking) psychiatrists’ process and occasionally cease the over-prescribing that still occurs.
This would also help to stop doctors from prescribing periods in seclusion ….in advance of anything happening. Yes it happens.
In Mental Health, diagnoses extends far beyond simple biochemical imbalances. Of course, it is easier to amend a chemical deficit or fault - eg thyroxine; insulin, where biological factors are at play and cause these mental health issues (ie psychosocial and behavioural difficulties); but not always will all these problems be ‘curable’ with a pill. Having a psych to differentiate organics is helpful.
I’ve derailed.
Anyhow, so of those 1 in 12, Shrink, of which the NPs referred none; how many were actually of the ‘1′? (I’m assuming 1 in 12 - so how many did they ‘miss’?).
If the screening process included those ‘other 1 in 12 causes’ then they’d be less likely missed? Or is the list too expansive? (I am genuinely clueless and have forgotten a lot of the dementia nursing studies I did years back).
Further, this is exactly the point that ought be picked up on by those with the wider knowledge and taught to the NPs - differentials and what to look for. It may be streaming a NP to only be efficient in one area when they have such wonderful generic skills for washing anyone’s bum - but isn’t that the nature of medicine itself? To generalise so they can all find a prostate then specialise in GP, surg, radiology, oncology, etc and become, eventually, a Consultant.
Rants’ arguments would have us consider that all medics should really be trained to Consultant level in every specialty going - otherwise aren’t we are just getting a Doctitioner?
Nurses are merely following the pathway of medicine that teaches generic then specialises as befits the career.
I vote we make medicine an NVQ IV certificate.
I think I’m done now.