Asking the Nurse First: What a Year of Practice Reveals

A year into asking residents to present from the nurse's perspective first, the residents stopped needing to be asked.

Issue 005 of this publication described a pre-round protocol we built into our residency program. Before the physician-centered presentation, residents reported from the nurse's perspective. Here is what the patient did overnight. Here is what the nurse is concerned about. Here is the functional trajectory. Then — here is what I think is happening medically. The protocol was built on an argument: that asking the nurse first would change how residents reasoned.

This essay is about whether that argument held. What actually happened when the argument became a practice that residents had to do, day in and day out, for a year.

The First Months: It Felt Like Translation

The first time a resident used the protocol, it felt like translation. The resident knew how to present in the medical frame — chief complaint, history of present illness, assessment and plan. The nurse's frame was foreign. The resident had to consciously extract from the nursing perspective, translate it into words, present it in the medical setting.

The resistance came in multiple forms. Some residents felt the nurse's report was less rigorous than the medical assessment. ("The nurse says he's 'not right,' but that's not how we talk about patients.") Some felt it added time to rounds. ("We're already running forty-five minutes behind.") Some felt it positioned the nurse as a decision-maker in a hierarchy where the physician was the decision-maker. ("I appreciate the input, but I need to see the patient and make my own assessment.")

The nursing staff noticed the awkwardness. Some nurses warmed to it immediately — they had been waiting for physicians to ask what they saw. Some nurses were skeptical that a formal protocol would actually change anything. Most nurses accommodated it without changing how they worked, understanding it as a residency training exercise that would pass.

What happened in the first months was not the argument. The argument was that resident reasoning would change. What happened first was a practice that felt like translation between two languages without integration. The two perspectives were still separate. The nurse's frame was being presented in the medical frame, which meant it was being translated and lost in the translation.

The Middle Months: The Questions Changed

Somewhere around month four or five, the questions the residents asked during their work with the nurse began to change.

They stopped asking questions that had yes/no answers and started asking questions that opened onto nursing reasoning. Instead of "Did he sleep?" they asked "What was his sleep like? How did he seem? What made you concerned?" They stopped collecting facts from the nurse and started asking the nurse how she was thinking about the patient.

This was not because we taught them to ask differently. This was not because we added a lecture on questioning technique. It was because they had to present from the nurse's perspective, and the only way to actually understand the nurse's perspective was to ask questions that went deep enough to understand it.

The residents also started anticipating what the nurse would say. One resident noted in the middle of rounds, before the nurse reported: "I think she's going to be concerned about how this patient handled his PT this morning." When the nurse reported exactly that concern, the resident had already incorporated the nursing framework enough to anticipate it.

The time issue resolved itself. Residents initially thought the protocol added time. By month four, the time was neutral or negative — rounds sometimes actually ran shorter because the nursing information clarified things that would have otherwise required additional workup or consultant questions.

The Later Months: Integration

By month eight or nine, the change had become less visible and more real.

Residents were no longer translating between two perspectives. They were integrating them. The assessment that emerged was no longer "the nurse thinks X, and I think Y" — it was a unified assessment that incorporated both the nursing and the medical frames as components of a single understanding of the patient.

One resident presented a patient like this: "She's ambulatory but deconditioned, got short of breath at the bathroom door yesterday, confident she'll be okay but the nurse is right to watch the trajectory. On exam her lungs are clear, O2 sat is 95% at rest. She was on supplemental O2 before admission; we're weaning her. I think we continue current course but I want to see her walk a few steps before we talk about discharge." That assessment incorporated the nurse's observation of deconditioning, the nurse's concern about trajectory, and the medical assessment of oxygenation and lung physiology — not as separate pieces but as parts of a single clinical judgment.

The residents were also reasoning differently about causation. Instead of asking "why did this patient get decompensated?" they were asking "what is this patient's trajectory in context?" A patient who is improving medically but whose functional status is declining is a different clinical problem than a patient whose medical markers are stable. The nursing perspective made that distinction visible.

The resistance had largely resolved by this point. Some residents remained skeptical — skepticism is fine, and healthy skepticism is part of clinical reasoning. But the skepticism was no longer about whether the protocol was valid. It was about specific clinical disagreements, which is the right level for skepticism to operate at.

What Changed in Clinical Reasoning

The observed changes across the year clustered into a few categories.

Reasoning became more longitudinal. Residents started thinking about patient trajectories instead of snapshots. The nursing perspective is inherently longitudinal — the nurse sees the patient across the day, across days. Integrating the nursing frame into resident reasoning meant that rounds conversations started to center on trajectory rather than on what was different in the last 24 hours.

Reasoning incorporated functional status from the start. Instead of functional status being something that got added near the end of the assessment ("also, the patient is weak"), functional status became part of the problem formulation. A patient with unchanged vital signs but declining ambulation is a different clinical problem than a patient with stable function and stable vitals.

Clinical reasoning became more inhabited. The assessment started to include not just "what is true about the patient medically" but "how is the patient managing the illness." A patient's confidence, anxiety, pain tolerance, and engagement in self-care are clinical data, not incidental observations. Integrating the nursing perspective made these observations central.

Residents asked better questions of nurses. The protocol forced residents to engage with nursing reasoning at depth. Over time, this became habitual. Residents who had learned to ask questions that accessed nursing perspective kept asking those questions.

What Did Not Change

The protocol did not make residents who were incurious suddenly curious. Some residents engaged with the framework deeply; others went through the motions. The depth of engagement correlated with the depth of clinical reasoning that emerged, but the protocol itself was a floor, not a ceiling.

The protocol did not produce uniformity. Each resident integrated the nursing frame differently. Some became intensely collaborative with the nursing staff; others maintained a more reserved stance while still incorporating nursing data into their reasoning. Both approaches worked.

The protocol did not solve the underlying hierarchies of the medical system. A resident can ask the nurse first and still practice in a system that ultimately privileges the physician's judgment. The protocol shifted local practice without shifting the larger structure.

What a Year of Practice Showed

The argument that asking the nurse first would change resident reasoning held. The change was not instantaneous; it required months of practice to integrate. The change was not uniform; residents engaged at different depths. The change was not total; the medical frame remained primary and the nursing frame remained subordinate in the hierarchy of the system.

But the residents who had practiced the protocol for a year thought differently about patients than residents who had not. They saw the longitudinal trajectory. They asked about function from the start. They incorporated what the nurse knew into what they knew. They asked better questions of the nurses they would work with in the future.

A protocol that requires residents to present from the nurse's perspective first seems like a small curricular intervention. After a year of practice, it was not small. It was the difference between residents who understood that clinical reasoning required two standpoints and residents who understood it in theory but practiced from one.

About the author

Peter Schindler, MD, PhD is an Assistant Professor of Medicine and Associate Program Director of the Community Health Center Family Medicine Residency Program at the University of Nebraska Medical Center. He practices at Winnebago Comprehensive Health System, OneWorld Community Health Center, and Nebraska Medicine. He completed a Primary Care Research Fellowship at McGill University and holds a BSN from the University of Wisconsin-Oshkosh, an MS and PhD in nursing from Emory University's Laney Graduate School, a Diploma in Tropical Medicine from the Liverpool School of Tropical Medicine, and an MD from the Medical College of Wisconsin-Green Bay. He is board certified by the American Board of Family Medicine. The Interprofessional publishes new essays every week at the intersection of medicine, nursing, and the clinical knowledge that lives between them.

Disclaimer. The views in The Interprofessional are Peter Schindler's own and do not represent the official positions of the University of Nebraska Medical Center, Winnebago Comprehensive Health System, OneWorld Community Health Center, Nebraska Medicine, or any other affiliated institution.