Puzzled about nurses' roles?

Doctors deserve most of the credit for writing prescriptions and making product decisions, but registered nurses and advanced registered nurse practitioners often have a say in what goes out the door with patients.

Sales representatives can avoid neglecting these powerful health care professionals by understanding the different responsibilities, influences and expectations that nurses have.

Know your nurses

Don't assume a nurse is a nurse is a nurse. While many office staffs may trade and share responsibilities throughout the day, there are certain distinctions between nurses that reps should remember.

Medical or clinical assistants may have some vocational training but they have limited pharmacological knowledge. They may play administrative roles within offices, or they may assist doctors by taking patient data such as medical history or blood pressure. But in general, they don't have as much responsibility and influence as licensed nurses.

Registered Nurses, on the other hand, have pharmacology training. They have a bachelor's degree and they understand and are interested in new medicines. They often know the side effects of medicines and want to be informed of the cost, efficacy and availability of a product. Although they are not trained as doctors, they are viewed by doctors as highly educated health care partners.

Licensed Practice Nurses have fewer years of school than R.N.s and are trained to take a more hands-on approach to health care.

Advanced Registered Nurse Practitioners have advanced degrees in nursing. In some states, they are even empowered with prescription-writing privileges. They can be powerful prescribers within an office and, in many ways, they are viewed by doctors as colleagues.

How can a sales rep tell the difference between who's a clinical assistant, who's an R.N. and who's an A.R.N.P.? In hospitals and many private practices, it may be as easy as reading their lapels. "Look at their name tags," advised Daniel Long, R.N., Glaxo Wellcome's regional director of Managed Health Care, Pacific Region. "Does it say R.N. behind the name?"

If name tags aren't used, however, the type of office where the nurse is working may be the next clue to what information they will want to hear from reps and how influential they are.

Clinical assistants have been supplanting registered nurses in hospitals and doctors' offices in recent years because they are less expensive to employ. However, their lack of advanced training prevents them from working with patients in offices where acuity or risk levels are high. R.N.s are more likely to be found in those settings.

"In a pediatrician's office, for example, you're likely to run into R.N.s," Long said. "The same is true for allergist, pulmonologist and gastrointestinal offices because of the possibility of infections and the risk of arrest. Doctors may want the higher level of education for procedures requiring sedation." Critical care settings are also heavily staffed with R.N.s, who are trained in advanced cardiac life support.

A.R.N.P.s can be found in a variety of settings. They're hard to see if they have prescription-writing privileges, though, because they're busy with patients.

Nurses' sway

As managed care makes more demands on doctors' schedules, the need for wise and effective nursing staffs grows stronger. Nurses who respond to that need build strong professional relationships with doctors, and the trust that stems from those relationships empowers them to talk with doctors.

Jan Ohlson works as an L.P.N. in an OB/GYN office in Bloomingdale, IL. As the nurse who answers telephone calls from concerned patients each day, she is the first to hear patients' reactions to new medications. She's also the first to respond.

"A lot of the calls are medication concerns," Ohlson said. "That's especially true when [a patient is on] a new regimen. They have questions about why it's not working, side effects, what happens next."

Ohlson follows standard protocols established by doctors in her office and she handles 80% to 85% of calls without a doctor's assistance.

If a patient complains of side effects that Ohlson believes can be eliminated by switching to another medication, then Ohlson will ask the doctor to rewrite the prescription. Sometimes he refuses, but he always listens.

"Personally, I think it's more important for a rep to focus a sales pitch toward nurses than toward doctors," Ohlson said. "Nine out of 10 times, the doctor already knows what the sales rep is going to say, and doctors are scheduled so tight that they really don't have time to see the reps. But if a rep can sell the nurse, then he or she's got a better chance of selling the doctor."

Linda Roberts, an R.N. and a nurse associate in the University of Chicago Hospital's cardiology department, described the four-doctor office where she works as "fairly collaborative." Because she works in a specialty where the level of acuity is high, she does not consider herself to be especially influential.

However, with 20 years of cardiology experience behind her, Roberts, 42, is older than all four of the doctors in her office. That career history enhances doctors' confidence in her judgment. "We talk all the time about products," she said.

Like Ohlson, Roberts and the other nurse in the office handle patient calls. "We're getting the initial response from patients. We tell them how to use [a medication], what to expect and what the possible side effects are." She also tells them to stop taking a medication if symptoms sound serious and there aren't any doctors available for consultation.

She occasionally makes recommendations to doctors about new or alternate medications, but doesn't expect the doctors to rely too heavily on her judgment. Neither Ohlson nor Roberts has the power to write a prescription for a patient. In fact, as nurses in Illinois, they work under one of the most restrictive state practice acts in the United States. If they were A.R.N.P.s in Florida or California, on the other hand, they might have greater influence in what medicines are prescribed to patients.

Joanne Hatchett, an R.N. and family nurse practitioner in Woodland, CA, made the transition from administrative nurse to F.N.P. two years ago.

Under California's limited practice act, Hatchett can "furnish" patients with certain medications. The "furnished transmittals" she writes are not considered as valid as prescriptions (those can only be written by doctors in California), but a patient can use one to obtain medicine.

The six doctors in her internal medicine department treat Hatchett like a colleague and discuss products with her. When challenged, however, she frequently defers to their opinions.

"If I have a question about a medicine or I'm not sure a patient's usual physician would prescribe my choice, I talk to that physician before I prescribe it," she explained. "It's a whole team effort."

As a new A.R.N.P. builds confidence in his or her judgment and expertise, he or she becomes a more independent prescription writer, according to M.J. Henderson, a geriatric nurse practitioner in an endocrinology office in Los Gatos, CA.

Henderson has been a licensed G.N.P. since 1986 and she works with just one doctor. Because the doctor is so specialized and aggressively tries new medications, Henderson defers to his judgment on some product choices, but not all.

Because of her experience in geriatrics, she often makes recommendations about lower dosages for older patients. Past experience from working in a urologist's office also emboldened her to take the lead on using antibiotics for shorter periods of time when treating bladder infections. The endocrinologist now follows Henderson's recommended antibiotic schedule.

Great expectations

Since nurses' responsibilities and influences depend so heavily on both the state and the type of office in which they work, reps need to customize their information accordingly. But keeping discussions educational rather than promotional is an effort appreciated by most nurses.

"We don't want to know sales projections," said one A.R.N.P. "We want to know clinical implications and how a product will help our clients. [A presentation] always has to be patient-focused."

R.N.s and A.R.N.P.s who were interviewed for this article expressed real disapproval of expensive programs that targeted only a handful of people. One A.R.N.P. asked, "If they're going to spend money, why don't they spend it on continuing education?" She went on to say that an excess of invitations to fancy promotional dinners from reps made her question their veracity when they told her medicines were high-priced because of research and development. "I'd rather they made the drugs less expensive," she complained.

More casual luncheons targeting larger audiences received better responses, and one L.P.N. quipped that gimmicks really do work. But she qualified that "they have to be simple, clever and help me remember the product."

Most hospital emergency room staffs have monthly meetings for their nurses. There are also American Nurses Association chapters in almost every state, and they have regular meetings too.

"If you get the name of a director or head nurse, say you want to provide some continuing education and some food at the monthly meeting, you'll probably get in," said Long. "Nurses will take the information and teach their patients. And because they're going to want to try new products, they will be all over the physicians, saying, 'You've got to try this stuff!'" PR