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.

[eCCU]

Cropp was the supervising pharmacist at Rainbow Babies & Children's Hospital on Feb. 26, 2006, when a pharmacy technician prepared a chemotherapy treatment for Emily.

The solution was 23 percent salt when the formula called for a saline base of 1 percent. Emily slipped into a coma after receiving the treatment and died on March 1.

As supervising pharmacist, Cropp had the duty to inspect and approve all work prepared by technicians before the drugs were administered to patients.

Cropp initially was charged with reckless homicide but agreed to plead no-contest in May to involuntary manslaughter. The State Pharmacy Board revoked his pharmacist license in April 2007.

Former pharmacist Eric Cropp gets 6 months in jail in Emily Jerry's death from wrong chemotherapy solution | cleveland.com

I hope they got slapped with enough lawsuits to last them a long long time....that's just plain ignorance on both the pharmacist for tolerating this and the hospital for not providing enough qualified staff!

[VICEDRN, BSN, RN]

I am curious......what makes you say the BSN nurse predates all other forms of nursing except the diploma nurse. What are you saying that ADN programs don't produce nurses? I am unclear......If this is true.....what you are saying is that my ASN program was a figment of my imagination.I do however agree that the academic achievement of the nurse in no way influences their clinical expertise and practice at the bedside.

Despite the endless and ever growing pile of studies that show that when there are more Bsn nurses in a unit, the less patient t mortality there is?I honestly can't believe that there are still corners of the nursing universe that haven't accepted this as a basic fact of life.And for brandonlpn, yes, the doctors care. They read those studies and now, they want to know why all the nurses aren't bsn and how crazy it is that we accept anything less for our profession. True.

[netglow, ASN, RN]

...and who really about what doctors think anyway? I mean, I don't seriously. They don't have much to do with well, anything.

[Esme12, ASN, BSN, RN]

Despite the endless and ever growing pile of studies that show that when there are more Bsn nurses in a unit, the less patient t mortality there is?I honestly can't believe that there are still corners of the nursing universe that haven't accepted this as a basic fact of life.And for brandonlpn, yes, the doctors care. They read those studies and now, they want to know why all the nurses aren't bsn and how crazy it is that we accept anything less for our profession. True.

I can't honestly believe that as a profession we can't seem to come to an agreement on the entry level education and that this subject is still being discussed 34 years later.

I just happen to believe that the degree does not always make the nurse......and nursing survived before the BSN degree. I think they are dumming down the curriculum to force a point. My niece is in an accelerated BSN program right now at the college I graduated from with my ASN. Her ABSN is my ASN program....it matches what I took exactly.

What I find beyond comprehension is That there are ADN/ASN programs out there that have been allowed to remove pathophysiology, pharmacology, ethics and legalities out of the ADN programs by the governing bodies stating that is for "higher education" is trying to sabotage the profession as a whole.

At one point the only difference between the BSN/ADN programs we the required electives. I find now that the curriculum has been down graded in favor of "higher" education. It remains that all nurses that pass NCLEX are all RN in the eyes of the law and the ADN must have some resemblance to the superior BSN education to enable all to pass the same exam.

There are corners of the nursing universe that don't necessarily have access to all of these "superior BSN grads" and actually do very well.

The studies that "prove" that the BSN makes for better outcomes are performed by the very individuals that are promoting their own agenda.....which for me negates their impact/validity in favor of promoting their own propaganda.

However......I do believe for the health of the profession there needs to be a singular entry level education for this constant discussion about one's superiority is old.

[dudette10, MSN, RN]

I hope they got slapped with enough lawsuits to last them a long long time....that's just plain ignorance on both the pharmacist for tolerating this and the hospital for not providing enough qualified staff!

According to the law, however, they did have qualified staff.

Have you ever watched behind the desk at your local pharmacy? The techs pull the scripts out of the bins, fill them, then the pharmacist rechecks them. I've watched the pharmacist open the bottle, look at the pills, look at the script, then sign off. I've even caught an error at my local pharmacy for a refill. The pills looked different than what I received before, although the label was correct. Ends up that the tech and the pharmacist both missed the error. Still not sure what was in the bottle.

When I've had to pick up a med from pharmacy, I've watched the same process. Tech gets the order, gets the med, labels it, takes it over to the pharmacist, and he/she signs off on the label. I've caught two pharmacy errors in the past week. One was an order for an oral med, and they sent up an IV med. The other was the wrong solution for the med in an IVPB. The order called for D5W, but they mixed it with 0.45%.

Always check your labels!

[turnforthenurse, MSN, NP]

And don't forget HCAHPS. This idea of "customer service" over my professional judgement is also leading to the deskilling of nursing, IMO.

[Esme12, ASN, BSN, RN]

The only thing that pharmacy techs do in my hospital is restock pyxis and bring up meds. We have a pharmacist in the I.V room whose job is to mix medications and others who accepts orders, process them and the tech brings the meds to the nursing station or pyxis.

Techs mixing sterile I.V drugs? ....where the heck is this?

Here is one..........

$8.25 Million Settlement Reached After Premature Infant Died From Fatal Overdose of Medication

According to reports by the Chicago Daily Law Bulletin, the infant was born three months premature, weighing less than 2 pounds. Nevertheless, during his stay at Lutheran General Hospital in Park Ridge, Illinois, he made “terrific progress through the 40 days of his life...and there was every reason to believe he was going to survive.”

A pharmacy technician working for the hospital prepared a prescription of sodium chloride to be given to the baby boy. Because of the technician’s negligence, the dose was more than 60 times the amount of sodium chloride that the physician ordered, and the child died of an overdose. The boy died in the arms of his mother who had suffered two prior miscarriages, reported the Chicago Daily Law Bulletin.

Following an immediate investigation into the infant’s death, the hospital changed its policy to ensure that each staff member double-checks intravenous bags so the label matches what’s in the bag. Nevertheless, because of the pharmacy technician’s carelessness, Lutheran General Hospital was liable for the child’s death.

Pharmacy technicians are an integral part of hospital health-system pharmacies. The National Association of Boards of Pharmacy defines pharmacy technician as a board-registered employee who may dispense medications, handle clinical conflict resolution, prepare IV admixtures, and prepackage and repackage medications under the supervision of a licensed pharmacist.¹

The Pharmacy Technician’s Role

The pharmacy technician’s role is evolving and varies widely between the retail industry and hospital health systems, as well as from state to state. Job descriptions and responsibilities have changed considerably over the past few decades. The impetus behind many of these changes is actually the desire to redefine the role of the pharmacist. Some states are looking to broaden the pharmacy technician’s role, allowing more control and responsibility for duties traditionally performed by pharmacists, such as clarifying prescriptions, reviewing orders for unacceptable abbreviations, and entering orders.

http://www.uspharmacist.com/content/d/feature/c/31431/

[eCCU]

Well...what can i say we are spoiled where we work, and the more i read about all these the more am glad i work where i do!!!!

We have a different clinical pharmacists assigned to each ICUs since they are quite busy. These pharmacist are to confirm physician orders and make sure they get to the pharmacist downstairs at the pharmacy. The clinical pharmacist also has to round with the physicians and other team members during rounds and is a great resource for everyone they are also rarely rotated as they have already developed a rapport with the team.

Again sorry but pharmacy techs don't fill meds my hospital! They might at other places just not here. Even specifically even asked this to her and she was like nope especially not iv!!

STAT meds like levo, amio, heparin, narcotics needed stat she literally goes to the pharmacy to pick them up and brings it to the nurse! Plus the facility has policies any mixed iv by the nurse as a stat should be replaced ASAP with one mixed by the pharmacist under sterile condition....again spoiled n loving it;-)

[eCCU]

I bet this dangerous errors do not scan their manufacturer barcodes to link up with their MAR and IV pumps...trying to save up the costs

[tnmarie]

Despite the endless and ever growing pile of studies that show that when there are more Bsn nurses in a unit, the less patient t mortality there is?I honestly can't believe that there are still corners of the nursing universe that haven't accepted this as a basic fact of life.And for brandonlpn, yes, the doctors care. They read those studies and now, they want to know why all the nurses aren't bsn and how crazy it is that we accept anything less for our profession. True.

Can you please site some of these studies? I've done a quick search myself and the primary studies I have found are more related to staffing ratios and nursing care environments than the education of the nurses on the units. The only study I found that considered education level of nursing staff was from JONA:

"Results: Controlling for patient acuity, hours of nursing care, and staff mix, units with more experienced nurses had lower medication errors and lower patient fall rates. These adverse occurrence rates on units with more baccalaureate-prepared nurses were not significantly better."

Source: Nurse Experience and Education: Effect on Quality of Care : Journal of Nursing Administration

[BrandonLPN, LPN]

I've never met a doctor in my life who gave a **** whether they were talking to a ADN RN or a BSN RN. And I'm willing to bet the vast majority of nurses here would agree...

[RN34TX]

Despite the endless and ever growing pile of studies that show that when there are more Bsn nurses in a unit, the less patient t mortality there is?I honestly can't believe that there are still corners of the nursing universe that haven't accepted this as a basic fact of life.And for brandonlpn, yes, the doctors care. They read those studies and now, they want to know why all the nurses aren't bsn and how crazy it is that we accept anything less for our profession. True.

There is no endless or ever growing pile of studies on BSN nurses and patient mortality. There has been only one study by Linda Aiken so it's far from being a basic fact of life. It's another example where if something gets repeated enough times, it starts to become accepted as the truth.