By T. Michael Britton, RN, NHA, WCC, DWC

As wound care professionals, we’ve all experienced a time when we felt that our patient didn’t have the appropriate wound treatment orders. However, the physician, nurse practitioner, or other prescriber wouldn’t follow your recommendation. This situation is not only frustrating but can delay the healing process. This article explores why a prescriber might not follow your recommendation and offers solutions. It focuses on physicians, because I’ve had the most experience with them.

Know the physician’s “type”

For 5 years, I was vice president of a company that managed physicians. I started asking them, “What makes you follow or not follow the wound clinician specialist’s orders?” Responses varied, but one response gave me an important insight. The physician told me there are three types of physicians: those who know, those who think they know, and those who don’t know.

With this in mind, the first thing you need to do is identify which of the three physician types you’re dealing with. Ask mutual coworkers who’ve worked with the physician, as well as the physician’s peers, for input so you get a feel for his or her personality. Then tailor your interaction based on your findings. For example, if a physician is the “think they know” type, prepare ahead of time what your response will be in case the physician disagrees with your recommendation. If a physician falls into the “don’t know” category, you’ll need to provide more detailed information about the nature of your recommendation.

Start off on the right foot

Your first interaction with the physician is crucial because it sets the stage for your ongoing relationship. When you introduce yourself, include all your credentials and don’t be embarrassed to talk about your training and experience. If possible, you already should have assessed the patient and reviewed the chart. It may be helpful to have someone familiar to the physician and who knows your expertise provide the introduction.

Make your case

Physicians say that clinicians who make a recommendation commonly aren’t prepared to provide the information the physician needs to make an informed decision. Having your information organized and readily available increases the chance that the physician will accept your recommendation. Many tools can help you get organized. One of the most user-friendly is SBAR—Situation, Background, Assessment, Recommendation. (See SBAR communication tool.)

Before you call or see the physician, be sure you can answer “yes” to the following questions:
• Have I seen and assessed the patient myself (instead of relying on someone else’s report)?
• Am I calling the right physician to address this situation? For example, can the patient’s primary care physician address the problem or do I need to call one of the consulting specialists?
• Do I know the admitting diagnosis and admission date?
• Have I read the most recent progress and nurses’ notes?
• Do I have the patient’s chart available so I can easily access information, such as age, current medication, wound treatments, allergies, laboratory results, and most recent vital signs?
• Do I know the patient’s resuscitation status?

Know what to do in the case of inappropriate treatment

If you believe the physician’s prior treatment orders were inappropriate, calmly express your concerns, and give rationales for your opinion. Be ready to cite a reputable source, such as protocols or research studies, to validate your position. Use correct medical terminology but don’t overcomplicate your language. Share your ideas for alternatives and try to get permission for a trial period.

Also tap into other resources, such as pharmacists, other physicians, and even product representatives, for information or support to make your case. For instance, a pharmacist may be able to bolster your argument for making a switch from one antibiotic to another.

If all else fails, report the problem to the appropriate supervisor.

Know when to suggest and when to recommend

It’s important to understand the difference between a suggestion and a recommendation. A suggestion implies a possibility or proposal. A recommendation is something presented as worthy of acceptance or trial. The difference is in the direction of the flow. A recommendation flows from upper level to lower level and between equals; a suggestion flows from lower level to upper level. Making a recommendation when the situation calls for a suggestion can lead to someone in a higher position than you being offended or feeling that you have overstepped your boundaries. On the other hand, using a suggestion when a recommendation is needed can result in the other party taking it as an option, something they don’t have to do; therefore, they don’t follow through.

An example of a suggestion from lower level to upper level is when a unit nurse says to the physician, “Dr. Jones, we are currently changing Ms. Johnson’s dressing three times a day. Studies have shown that dressings should be removed as infrequently as possible to prevent excess wound cooling.”

Here’s an example of a recommendation between equals is this interaction between a unit nurse and a wound care nurse: “We should change Ms. Johnson’s dressing change from three times a day to every day. Her drainage has decreased and we can reduce the wound’s exposure time.” Note that the unit nurse provided a rationale for her recommendation.

Here’s another example of a recommendation: As the wound care expert, you’re consulted to evaluate a patient in a long-term care facility who continues to have skin breakdown. After reviewing the medical record, you realize the patient is being turned only once every 3 to 4 hours. When you meet with staff on the floor, you state,
“Ms. Johnson has had two pressure ulcers in the past 6 months, and has a history of diabetes, which can affect healing. She’s at high risk for skin breakdown, so she needs to be turned every hour.” Again, note that support is provided for the recommendation.

Pick your battles

It’s not important to win every battle. Instead, remember that you want to win the war. There will always be some physicians and other prescribers who aren’t willing to follow your suggestions. As professionals, we have to accept that. Of course, if a physician’s unwillingness to follow your suggestion puts the patient at risk for harm, you’ll need to take your case to the next level.