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.

[Jory, MSN, APRN, CNM]

I think the balance is what's important. I just found out that repairing central lines has gone from being a surgeon's job to a nursing job. Which is great! Turning over less-skilled functions is fine as long as at the same time we're taking on more-skilled functions.

I think the real problem comes from billing. As long as another department gets to charge, and nurses continue to earn no more for the hospital bottom line than the curtains in the room (but cost a lot more than the curtains), hospitals will look to find ways to cut our numbers. Other departments have found ways to ADD to the bottom line. RTs charge for each treatment. PTs charge for each wound treatment or therapy session. But nurses continue to just be bundled in with the room. Until nursing can start BILLING FOR OUR SERVICES, we're going to be considered merely a very expensive piece of furniture in the patient room.

I actually don't know of a single PT or RT that gets to "bill" for services. Yes, these charges for services shows up on the patient's bill, but those folks get paid an hourly rate just like I do.

[TheCommuter, BSN, RN]

I actually don't know of a single PT or RT that gets to "bill" for services. Yes, these charges for services shows up on the patient's bill, but those folks get paid an hourly rate just like I do.

At the facility where I work, PT, OT, and RT get to submit 'charges' for every task or service that they perform on each patient.

Although these people are compensated in the form of hourly pay or flat salaries, those 'charges' that they submit generate tons of revenue for the hospitals that employ them. Therefore, healthcare facilities love having PT, OT, and RT on the payroll.

On the other hand, nurses cannot submit 'charges' for every task that we perform. Since nurses cannot drum up revenue in the form of 'charges,' the administrative staff at hospitals dislike having nurses on the payroll because we are viewed as just another huge expense.

The ability of PT, OT, and RT to submit 'charges' and 'bills' might not add to their pay, but it surely adds big bucks to the hospital's bottom line. Nurses cannot submit 'charges' and 'bills,' so we actually take away from that precious bottom line.

[Rnandsoccermom]

At the facility where I work, PT, OT, and RT get to submit 'charges' for every task or service that they perform on each patient. Although these people are compensated in the form of hourly pay or flat salaries, those 'charges' that they submit generate tons of revenue for the hospitals that employ them. Therefore, healthcare facilities love having PT, OT, and RT on the payroll.On the other hand, nurses cannot submit 'charges' for every task that we perform. Since nurses cannot drum up revenue in the form of 'charges,' the administrative staff at hospitals dislike having nurses on the payroll because we are viewed as just another huge expense.The ability of PT, OT, and RT to submit 'charges' and 'bills' might not add to their pay, but it surely adds big bucks to the hospital's bottom line. Nurses cannot submit 'charges' and 'bills,' so we actually take away from that precious bottom line.

You hit the nail on the head. "Nursing care" is included in the overall cost of services. I envision that in the future there will be one or two highly educated nurses "supervising" all the tasks be performed by services who can all charge separately. Therefore the hospitals will need less of us. We are educating- meaning pricing ourselves right out of the market I hate to say.

[BrandonLPN, LPN]

I dot think I could sleep at night if I had to explicitly bill patients for medicating them or for dressing their wounds. It seems sleazy somehow....

[TheCommuter, BSN, RN]

I dot think I could sleep at night if I had to explicitly bill patients for medicating them or for dressing their wounds. It seems sleazy somehow....

It might seem sleazy, but healthcare facilities actually prefer to have workers on the payroll who can 'bill' or 'charge' for each service rendered because this activity generates profits. It increases the total amount due on the patient's bill, which increases the cash flow to the healthcare facility.

Since nurses cannot 'bill' or 'charge' for each service that we render, we are considered huge expenses that detract from the healthcare facility's profit margins.

[ThePrincessBride, MSN, RN, NP]

I'm going to say something that is going to **** off a lot of people on this thread, but here it goes:

You can't have it both ways. Nurses seem to be so divided on this issue. I got into a heated discussion with a nurse not too long ago who stated she didn't feel as though PCAs should be allowed to collect vital signs or perform accuchecks b/c "PCAs lack critical thinking skills." You know how insulting that is to someone who is a PCA? We aren't all unintelligent monkeys. :)

And then there are nurses who complain about being over burdened. So...which is it? You feel that you are being overburdened or that your skills are being stolen by PCAs who "lack critical thinking skills."

I will say that I do agree: There shouldn't be "medication aides" in this profession. I feel that only nurses and doctors and other licensed professionals should be allowed to pass medications. However, drawing blood and wound changes? Not so much. Those are simple skills, imo.

Nurses will NEVER be "outed" from the medical field. That is an absurd notion. Nursing is evolving, yes, and I would even go as far as saying that nursing has become more complex, including the assessment process. Nurses aren't going anywhere, and I think it is insane that some people think that techs will absorb a LICENSED profession such as nursing.

[kitty13]

"Nurse" is defined by the state board of nursing as licensed to practice within their scope. Any MA, CNA, that represents themselves as a nurse is or can face charges should the SBON catch them. I have been on the state board investigation side. It does happen and sometimes it is a very smart patient who turns the individual in. It may be someone who works for JACHO and overhears. Bottom line the cna, ma, pca must have some administration guidance and a good licensed "nurse" to remind them it is not within their scope of "care" to identify themselves as nurses but rather if asked they should state i am your care aide or just say i am the aide.

[Rnandsoccermom]

Interestingly a couple of the area hospitals where I live have a "robot" that actually rounds on patients. It has a video screen with a MD connected to the other end of it. Obviously it is not being used on critically ill patients but it is being used. As more corporation-like hospitals hone their businesses we don't really know what will happen. The bean counters where I work think we should turn off the lights at night, it costs money to keep them on 24 hours a day. I'm waiting for my night vision goggles to be issued.

[nursel56]

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.

I think the fact that they aren't talking about that is shameful. They don't want the pipeline slowed one bit, effectively declaring they have no problem piling another layer of unemployed new grads on the older one. There is so much that could be done to raise awareness through their existing bully pulpit, but they haven't budged an inch on the issue. In fact, they've dug their heels in and actively attempt to discredit those whose don't believe there will be a shortfall of 1,000,000 nurses by the year 2020. (that is so far the most egregious example)

I believed for quite a while that they would eventually put the plight of old-new grads front and center, out of sheer decency, but they will never do it. Realizing that "nursing shortage" is increasingly being seen as ludicrous by anyone who lives in the real world, they are not deterred - now we're seeing stuff creep into their rhetoric like, "will we have enough educated nurses and not substandard nurses(that's code for ADN nurses, LPNs are complete non-entities to them)??" or "the shortage is in faculty, it's a crisis!"

I would say to plan on this issue being ignored, willfully, because to acknowledge reality and really be "the voice of nursing" you wouldn't be busy dreaming up the most persuasive verbiage that ignores the elephant in the room. It's about money. How crass that is. This website should be required reading by executives at the ANA and AACN. Maybe if they actually got it that these are real people and not some faceless statistic to bandy about while you're busy on The Hill within arms reach of the people who do have the power to mitigate circumstances.

[Esme12, ASN, BSN, RN]

It might seem sleazy, but healthcare facilities actually prefer to have workers on the payroll who can 'bill' or 'charge' for each service rendered because this activity generates profits. It increases the total amount due on the patient's bill, which increases the cash flow to the healthcare facility.

Since nurses cannot 'bill' or 'charge' for each service that we render, we are considered huge expenses that detract from the healthcare facility's profit margins.

What commuter says is right......I see Nurse Practitioners at the bedside for their billable abilities.

[OCNRN63, RN]

I have heard many CNAs claim that they have a right to be included within the professional nursing associations because they are a nurse's assistant. Some might say that if you can lump the LPNs and RNs together then you can lump in CNAs and techs too. Why do you want to exclude a CNA or tech?

Some might argue that only RNs should use the term nurse...just to stir the pot.

Do not CNAs perform bedside nursing tasks too?

CNAs are not nurses. Yes, they are vital to providing patient care, but they do not possess a unique body of knowledge as nurses do.

Housekeeping feels overlooked. Maybe we should call them nurses, too. What the heck, just call everyone a nurse so no one gets their panties in a bunch.

This mentality is what comes from the "Everybody is a winner and gets a trophy" thinking.

[tothepointeLVN, LVN]

Pretty soon we will have licensed healthcare associates. All specialized in one area only so they have few career options.