The 'De-Skilling' Of Nursing

The reality of technicians and other professionals taking over aspects of the nurse's role is a valid threat that should not be handled lightly. If there's even one jobless nurse in society who desperately wants to secure employment, then the 'de-skilling' of nursing is certainly a problem. The nursing profession must stop giving up skills to other members of the healthcare team. This article attempts to explain how the nursing profession is being 'de-skilled.' Nurses Announcements Archive Article

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.

Magnet status is somehow subverting patient care?

I'll agree with THAT one. In addition to caring for the ridiculously high number of patients, we have to make sure to keep up with our career ladder points and participate in committees where the only point is to pretend nurses have a say when it won't actually make a bit of difference if anything the nurses say will cost money or effort on the part of non-nurses.

0 Votes
I'll agree with THAT one. In addition to caring for the ridiculously high number of patients, we have to make sure to keep up with our career ladder points and participate in committees where the only point is to pretend nurses have a say when it won't actually make a bit of difference if anything the nurses say will cost money or effort on the part of non-nurses.

That would be an issue with the facility administration, not with magnet status.

0 Votes
That would be an issue with the facility administration, not with magnet status.

What problems are magnet status supposed to solve? Are those problems being solved through a hospital's attainment of magnet status? Are patient outcomes better? Are nurses' working conditions better?

Magnet status: What is is, what it is not, and what it could be

Working Conditions for Nurses: Does Magnet Status Make a Difference?

0 Votes
Specializes in Med-Surg Telemetry.

I think it depends where you work.

I work for the VA since my externship in two different VA medical centers (within a VA system) and currently in another one in a different state. In the first VA system, certain tasks were given to other departments, for example: respiratory techs administer the nebulizer treatments and PT techs would put the total knee replacement patients on CPM therapy.

But in the current VA med center I work in, I do all those things myself. I personally like it this way because I don't have to wait for other people to do them and I can assess and do any additional care that's needed. As for wound care, it depends. If its surgical stuff, then orders normally are to just reinforce and notify the surgeon, but we do most other types ourselves.

I also agree with wooh - we may lose some tasks to other departments, but we do get to acquire some skills that an MD/surgeon might normally do. As wooh had mentioned, RNs here are can administer Cathflo with an MD order for occluded central lines - metoprolol IVP in certain circumstances also comes to mind. It's not much but it's something. I think most of the doctor skills given away are to the nurse practitioners though (think nurse anesthetist), which I don't mind. I may want to go on to that some day, God willing.

Also, Despareux had mentioned CNAs. In my unit, they are phasing them out along with the LPNs, meaning they are keeping the ones we already have, but no longer hiring new ones so that the RNs are pretty much doing everything. This seems to work out well so far but I think it's because we have a decent patient-to-nurse ratio and everyone is willing to help each other out. I don't think this will work otherwise.

Right now, we only have two CNAs in the entire unit, one on evening shift and one on night shift and three LPNs, one on each shift. We had more, but a lot of them went to the nursing home units and one LPN went to telehealth. I really value the ones we still have - they have tons of experience and knowledge. So for hospitals with units like mine, the concern is more for CNAs and LPNs where we're kind of shoving them off to less acute areas.

0 Votes
Specializes in LTC Family Practice.

I agree with the OP, I've watched this happen over the last 40 years. First they ran us (LPN/LVN) out of the hospital setting and replaced us with CNA or Techs who've had a minimum of 4 weeks of task related training. As an LPN I was trained at the bedside to be a bedside nurse. We were trained to assess with critical thinking skills (yup that's right folks) look for opportunities to evaluate and talk with the patient at all times. I've also watched our scope of practice explode not just expand over the last 40 years. For the last year I've worked as a non-medical patient sitter and have watched what kind of care is given to the patient, I'm often ignored by staff when they are in the room because they don't realize I'm an LPN who let my license lapse in this state. Quite frankly the bedside care these patients get is abismal. The RN's are so overwhelmed its pathetic, the CNA/Tech's have a huge patient load and not only don't have the time but really don't have the skills.

I also agree that we should have a national nurses union, however, I also see the one mentioned doesn't include LPN/LVN's. For years we've been shuffled off and all of a sudden the want us included...That'd be great so where is this national union that's all inclusive of licensed nurses.:cool: I have advocated for a national licensure agency for years, if we as nurses both RN and LPN/LVN have a national licensure it would also lend itself to have a national voice for ALL licensed nurses. We've been divided for so long, many RN's today have never worked with an LPN/LVN and have no idea what we can do and our skill level.

My years of working in a hospital were great, the patients got outstanding care, those hospitals only hired RN's and LPN/LVN's - no CNA's no Techs. Those patients got TRAINED and Licensed nursing care.

What I'm wondering is how to un-ring the bell, can it be done? As long as we have for profit health care in this country where the bottom line is more important than the patient...well you know the answer and it's no.

0 Votes
Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
I think most of the doctor skills given away are to the nurse practitioners though (think nurse anesthetist) which I don't mind. I may want to go on to that some day, God willing.[/quote']Anesthesia was strictly a nursing skill once upon a time, until it was relinquished to physicians. Obstetrics was also a nursing skill before it was surrendered to physicians.
0 Votes

I see LPN's and RN's seem to be on the same page so when and how we are going to organize? All nurses .com is a great platform however we need to be serious about taking back what is our skills ..............We need to start to organize and have a solid platform to stand on to appeal all LPN's and RN's on a whole........:)

0 Votes
Specializes in Hospice / Ambulatory Clinic.

I think what we will find is the tech roles will start to become more regulated and licensed and schools will pop up to teach these trades because really if your going to "phase" out the LPN's and ADN and Diploma nurses then something will fill their place. Just search AN for "Did I really go to college to wipe butts" to see why.

0 Votes

Great article! Many good points. It's not clear to me that nursing is necessarily being de-skilled. It's just that we need to continually update our skill sets. As other posters have pointed out, what nurses do today, physicians use to do. In many cases, nurses have invaded other discipline's territory as it were and become the bain of that other discipline's existence.

Health care facilities are in the money making business, for-profit or not, and if they deem their reimbursement levels to be too low to pay wages and benefits for licensed workers then unfortunately caregivers and our patients suffer. I do agree with some of the assessments that point out that nurses may need to make an effort to become independent practitioners while providing care at the bedside. I think those of us with graduate nursing degrees can make that case as long as the scope of practice supports it.

Some nurses feel that the problem of de-skilling is as a result of too much focus on enhancing the educational requirements for nurses. I contend that the fact that our profession is so fragmented is the cause of much of our agony. We have unlicensed nurses, ranging from CNAs to RMAs, as well as licensed nurses, RNs and LPNs. Practically anyone calls him/herself a nurse, but you don't hear much of that with therapy or pharmacy. So, I contend (I know darts will be thrown in my direction) that part of the problem with de-skilling lies with us not accepting that we need to standardize nursing educational requirements. That will partly solve the nurse educator shortage as well as the de-skilling problem. Alright, let me have it!

0 Votes
Anesthesia was strictly a nursing skill once upon a time, until it was relinquished to physicians. Obstetrics was also a nursing skill before it was surrendered to physicians.

Obstertrics was never "surrendered" to physicans/hospitals/medicine; rather there was a huge conspiracy to push midwives out and claim the area for doctors (men).

Midwives were most always women whom often came with vast experience and knowledge (often passed down orally) of various herbs and techniques that could be used in the care of women, pregnancy and childbirth. This last bit was to be the undoing of midwives as it was used to brand most of them as "witches" or "abortionists". I mean afterall how could a pack of women who by nature and God's own design were inferior to men possibly know more about childbirth or women's health?

While it is true many midwives did know about several herbs that would induce labour which could be used either to bring it on for a woman who as past her time, or cause a miscarrage, it was hardly main reason for getting shot of them.

Pig headed doctors with their newly built lying in hospitals and or poor techniques were responsible for the large numbers of childbed fever cases which carried off thousands of women and newborns. Dr. Semmelweis was the first physican to make the connection that women who delivered at home by midwives and or away from the filthy hospitals had less indices of puerperal fever, he then set out to find out why. Even after his discoveries regarding hand washing and sanitation regarding L&D his male dominated physican community refused to listen, and women continued to die. It would take years after his death for his theories to be vindicated.

Long story short pregnacy and childbirth were moved by physicans into the realm of a "disease" that must be treated and "cured", something midwives and others knew was hogwash.

The happy ending if it can be called that is in many parts of Euorpe and around the world more infants today are delivered by trained/licensed midwives than physicans with apparently excellent outcomes, even when those births take place at home.

0 Votes
I think what we will find is the tech roles will start to become more regulated and licensed and schools will pop up to teach these trades because really if your going to "phase" out the LPN's and ADN and Diploma nurses then something will fill their place. Just search AN for "Did I really go to college to wipe butts" to see why.

This really sad to see so many of the once great "nursing arts" reguated to the rubbish bin of the profession and or otherwise deemed unworthy of modern practice. As late as the 1980's bed making, patient bathing, ambulation and so forth were a major part of "Med/SurgI" or whatever first year class a nursing program gave it's students. Guess it seems funny today to be graded and having to pass exams on making three types of beds, but there you were.

Being as all this may it proves that everything old is new again.

Before the Nightingale model of nursing care took over nurses were usually high born women (the only ones with enough education to read and write), who performed what we would call planning patient care today, the actual work was done by non-nurse "UAPs" if you please. Catholic religious run insitutions were famous for this particuarly in France (a very late adopter of the Nightingale methods). Nurses never touched a patient if they could help it, that simply wasn't what they "did".

With the explosion of women entering convents and or the workforce providing cheap labour, the Nightingale methods refined over the years were inexpensive to implement. Aside from certain periods in modern history, usually around major wars, hospitals had sufficent supply of "cheap" labour from mainly female nurses

0 Votes

I have been saying for years, that nursing needs to go to a BSN as entry into practice, and grandfather in the ADNs and Diploma nurses.

LPN/LVN needs to go to an Associates Degree and entry into practice. Physical Therapy Assistants have a two year associates degree as entry into practice, and they never do anything that comes close to endangering a patient like LNPs do.

The BSN need to be re vamped. Some of the fluff can be done away with, classes like, "How To Run a Business", "Legal Aspects of Nursing and Patient Care", "Employment Law", need to be included.

These type of classes are included in the class work of PTs OTs, etc. Nurses are too naive in these areas, and that is why they are pushed around like they are. If you do not know the law, you can be too easily intimidated by managers, etc. Ignorance is not bliss in the work place.

A higher level of education will make us less likely to be replaced by lesser educated individuals. A two year associates degree is looked as more easlily replaced by a MED tech or nurses aide, with a minimum educational level.

Unionizing will give you the support to be able to go out to the public and educated them as to what is going on in the hospital. Let them know that the hospital is trying to replace college educated RNs with not much more than HS dropouts. The public doesn't complain because they do not know who is taking care of them, how many patients your are assigned to, etc. If something goes wrong, they throw the nurse under the bus and blame the nurses instead of the managers who are assigning too many patients to each nurses.

Think outside the box!

JMHO and my NY $0.02.

Lindarn, RN, BSN, CCRN

Somewhere in the PACNW

0 Votes