The 'De-Skilling' Of Nursing

[TheCommuter]

What should be our greatest concern for the future of nursing?

We must fear the day if (or when) registered nurses (RNs) and licensed practical nurses (LPNs) will be less needed in healthcare due to systematic de-skilling of the nursing profession. Even though patients are becoming sicker and more complex in today's healthcare system, other professionals and paraprofessionals have started to perform tasks and assume roles that had once been within the strict realm of licensed nursing personnel.

The de-skilling of the nursing profession has been taking place for quite some time. For example, we have phlebotomists and phlebotomy technicians to draw blood in certain healthcare settings.

Medication aides regularly administer medications in many nursing homes, group homes, and assisted living facilities, even though the task of medication administration had once been a duty that was strictly performed by licensed nursing staff.

Some hospitals have policies that allow patient care assistants to insert and remove indwelling urinary catheters and discontinue peripheral IV catheters.

Some rehabilitation facilities and specialty hospitals have assembled wound care teams that consist of physical therapists and occupational therapists who perform all the dressing changes and handle all the complex wound care cases.

Many back office medical assistants now perform advanced skills in doctors' offices under the supervision of the physicians who employ them.

Pharmacy technicians now mix medications in hospitals on a regular basis, but RNs were once able to mix drugs in piggybacks for IV administration.

Rehab techs now ambulate patients post operatively when licensed nursing staff used to be the ones to ambulate 'early and often.'

More examples of de-skilling in the nursing profession exist. For instance, many healthcare facilities employ lay people to do the staffing and scheduling for nursing staff. These schedulers are given the fancy titles of 'staffing coordinator' or 'director of staffing,' and have been given responsibility for an administrative aspect that nursing management or supervisory staff strictly performed once upon a time. In addition, some emergency departments are considering hiring paramedics to lessen the need for ER nurses.

The writing is on the wall.

The nursing profession must stop surrendering our valuable skills to other healthcare workers now. Nurses need to fully embrace their skill sets and constantly be on the lookout for other disciplines who are attempting to remove yet another skill away from our roles. If even one unemployed nurse exists who needs a job, then de-skilling is a problem because non-nursing staff are displacing licensed nurses. If this systematic de-skilling does not stop anytime soon, the future of nursing might be in trouble.

[arallenrn11]

I am a relatively new RN (about 14 months). What I hear from more experience nurses is that the level of acuity has increased dramatically from say 15 years ago. I know that as a fairly new nurse I would not physically be able to complete all the tasks that other departments take care of. From pharm mixing most meds to RT performing treatments and lab doing draws. There is simply not time in my shift. The only way that would ever be possible is if I had like 2 or 3 patients versus my usual 5 to 7. And that will never happen because supposedly it's not "cost-effective." Nursing then and nursing now are two different professions. I frequently wonder how different we would all feel if we were nurses in Florence Nightingale's era. Did she feel the same pressures?

[Asystole RN]

How does my existing (or ADNs) prevent you from being a professional? So we have a multi tiered nursing model that includes LPNs and ADNs. So what? If BSNs want to be viewed as professionals why don't we make the BSN an exclusively management position? You'll still need someone to delegate the bedside tasks to. Or would you rather delegate them to an army of unlicensed personel?

The term profession is actually something that is defined by social scientists and there are specific characteristics that an occupation has to achieve in order to be identified as a true profession. Currently nursing is known as a developing profession, not a true profession.

One of the big things holding back nursing is the lack of a unified level of entry or pathway of education.

For example lawyers have X amount of school and a defined pathway. Physicians have X amount of school and a defined pathway. Nurses have a variable amount of school, depending on what type of nurse, and variable pathways.

There is more to it but that is one of the reasons why the push for a standardized BSN level of entry into the profession.

[BrandonLPN, LPN]

I would like to add that part of the reason nursing *needs* different levels of nursing is because it's so broad an occupation. There are so many different levels of care and facilities with different types of accuities. In a LTC facility a BSN RN

is overqualified as a staff nurse. But it's perfectly suitable to a LPNs level of training. The LPN will be more likely to stay, which is vital in a long term care model where stability is key. I notice that most of the nurses pushing to eliminate the LPN and ADN work in hospitals. If you worked in LTC, you'd realize that multiple levels of nursing is essential.

[Asystole RN]

I am a relatively new RN (about 14 months). What I hear from more experience nurses is that the level of acuity has increased dramatically from say 15 years ago. I know that as a fairly new nurse I would not physically be able to complete all the tasks that other departments take care of. From pharm mixing most meds to RT performing treatments and lab doing draws. There is simply not time in my shift. The only way that would ever be possible is if I had like 2 or 3 patients versus my usual 5 to 7. And that will never happen because supposedly it's not "cost-effective." Nursing then and nursing now are two different professions. I frequently wonder how different we would all feel if we were nurses in Florence Nightingale's era. Did she feel the same pressures?

You should read her book, Notes on Nursing. It is a fantastic read and sheds light onto modern nursing, you would be surprised at the similarities in nursing...

[Asystole RN]

I would like to add that part of the reason nursing *needs* different levels of nursing is because it's so broad an occupation. There are so many different levels of care and facilities with different types of accuities. In a LTC facility a BSN RN is overqualified as a staff nurse. But it's perfectly suitable to a LPNs level of training. The LPN will be more likely to stay, which is vital in a long term care model where stability is vital. I notice that most of the nurses pushing to eliminate the LPN and ADN work in hospitals. If you worked in LTC, you'd realize that multiple levels of nursing is essential.

I have worked in sub-acute care for most of my career, and still do PRN. I would agree that there needs to be multiple levels of care.

I predict that the future of nursing will have the BSN nurse finally become the standard of entry to be a registered nurse and LPNs will be left but required to have an associates degree. I would not be surprised if the two forms of nursing completely split into entirely separate professions with different educational pathways and different regulating bodies.

[gummi bear]

It's kinda sad to see that some of you think that CNAs are a part of the problem and not a part of the team present to assist nurses. At my hospital, many nurses are more than happy to pass off "basic nursing skills" to the CNAs because they have "more important nurse stuff to do". Yes, some of them actually think this way, and have no problem saying so. Some of them try to have minimum physical contact with the patients as possible because they don't feel like dealing with the patients. And then you have the nurses on the opposite end of the spectrum, who'll do whatever it takes to get the job done and provide efficient patient care no matter what the task is. I think that most of this "deskilling" is being driven by nurses in higher positions with multiple degrees who no longer work at the bedside, and have "better things to do" than to assist patients with ambulation, insert catheters, and obtain vital signs. Blame these types nurses for the deskilling of the nursing profession, not the CNAs that are right next to you working their butts off, and often trying to attain a higher education at the same time too. These antibedside nurses are so preoccupied with trying to gain the same respect and recognition as physicians, that they start to believe that they are above and beyond giving basic nursing care.

[BrandonLPN, LPN]

The term profession is actually something that is defined by social scientists and there are specific characteristics that an occupation has to achieve in order to be identified as a true profession. Currently nursing is known as a developing profession, not a true profession. One of the big things holding back nursing is the lack of a unified level of entry or pathway of education. For example lawyers have X amount of school and a defined pathway. Physicians have X amount of school and a defined pathway. Nurses have a variable amount of school, depending on what type of nurse,and variable pathways. There is more to it but that is one of the reasons why the push for a standardized BSN level of entry into the profession.

All right, so why not say that BSN and higher is a separate profession in itself. We LPNs will be licensed to practice "practical nursing". BSNs are licensed to practice "professional nursing". Where's the problem in that. If you're point is to strip the LPN of the title "nurse", well you're wasting your breath. They can pry that from my cold, dead fingers.

[pookyp, LPN]

It's kinda sad to see that some of you think that CNAs are a part of the problem and not a part of the team present to assist nurses. At my hospital, many nurses are more than happy to pass off "basic nursing skills" to the CNAs because they have "more important nurse stuff to do". Yes, some of them actually think this way, and have no problem saying so. Some of them try to have minimum physical contact with the patients as possible because they don't feel like dealing with the patients. And then you have the nurses on the opposite end of the spectrum, who'll do whatever it takes to get the job done and provide efficient patient care no matter what the task is. I think that most of this "deskilling" is being driven by nurses in higher positions with multiple degrees who no longer work at the bedside, and have "better things to do" than to assist patients with ambulation, insert catheters, and obtain vital signs. Blame these types nurses for the deskilling of the nursing profession, not the CNAs that are right next to you working their butts off, and often trying to attain a higher education at the same time too. These antibedside nurses are so preoccupied with trying to gain the same respect and recognition as physicians, that they start to believe that they are above and beyond giving basic nursing care.

So true.

[tothepointeLVN, LVN]

Lower level nursing? Are you implying that the work performed by LPNs is somehow below the level of work performed by RNs?

I think the idea is that BSN nurses would fill the home health, SNF, and other sub acute positions.

Although, just as LPNs often are overlooked by RNs, the sub acute healthcare scene is often overlooked by acute care. Since acute care RNs dominate the national political nursing scene they do not readily address non acute care issues.

As I said before I'm not in the acute care setting trying to pretend I'm just as good. So not implying stating. My job is more hands on less technical less demanding but still nursing. Community based nursing requires critical thinking but usually one patient at a time so that's obviously easier. It's rewarding and not too stressful but I can't imagine wanting to do it once I have my BSN certainly not at LVN rates. So economics will have to be considered. I became a LVN once most of the shift into less acute areas had already occurred so I'm not chasing something that's not coming back.

[SHGR, MSN, RN, CNS]

I get the desire for standardization, but there's benefits of having a multi tiered system. I actually think there is some merit to the idea of *forcing* nursing to be a career taken on a step by step basis. A requirement to get into a LPN program is having worked for a year first as a CNA. A requirement to get into a RN program is having worked for a year as a LPN. Thus no new RN could possibly step into a RN job without already having solid nursing experience. Nursing schools do such a pi** poor job of preparing nurses for the real world, some real world experience could only help.

I have thought this for a long time, and thank you for articulating it so clearly. It's like the ancient Greek system, actually. Also, like training for the NP role was originally conceived. Nursing and patient care would exist on a continuum, with knowledge and skills building on each other, in such a system.

[luv2]

I am displeased with the actions of the delegates of the ANA..... because honestly..... at this point I AM thinking what delegates?....they have the name but no action....How many of them are addressing the facts hundreds of new/old graduates RN are being turned away from working everyday as R.N's and LPN /LVN's. How about the fact that many health care facilities prefer to hire 12 cna or techs or care companions as oppose to nurses....How have they address this concern? How about meds being administered via med tech...how have they addressed this? How about ECG being performed by EKG tech or cna.....how about vitals signs being done by cna......and the nurse has to go back and check it again.....how about cultures being done tech or cna .....and we have to take it again because it was done wrong....how about blood being taken by phlebotomist.......How about in some hospital or other health care facilities in the OR there NO RN's just surgical tech.....the scrub nurse is only there when JACHO is visiting.....I could go on and on? ...Where are the regulations? Where is the tone? . These ANA people in my opinion are NOT representing my interest.....When was the last time you went on the ANA website? ..... no offense somethings are outdated and they are on their website. The governance structure does not use its power to advance the nurse. It makes rules and regulation for nurses, but no follow up.It DOES NOT organize us nurses rather it divides because it does not include LPN/LVN. It has not organized us as NURSES to make political stands. Imagine if it was important for who ever was running for office to get a our support as NURSES.....we could take a stand as one united body. However, they have never tapped into their ability to create UNITY.....

[tothepointeLVN, LVN]

I predict that the future of nursing will have the BSN nurse finally become the standard of entry to be a registered nurse and LPNs will be left but required to have an associates degree. I would not be surprised if the two forms of nursing completely split into entirely separate professions with different educational pathways and different regulating bodies.

Honestly that sounds like a fine idea and similar to something I suggested except mine was phase out the LPN's. Make the ADN then entry level nurse and make the BSN Nurse + with the expectation that having a BSN mean you already had experience and thus could benefit from the added education.

When it comes down to it my view point as a nurse is I just want to be utilized appropriately. I would embrace a clearly defined role even if it was a little restricted. Though this embrace for me would be fleeting as I'm actively working on transitioning but still.