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.

[Asystole RN]

Much of the nurse educator problems in many areas of the USA at least revolves around money. Master and higher degree holding RNs simply can earn more today in hospital or other capacities with often less aggravation than teaching.

To me the problem lies where others have hinted or come outright and stated, politics.

Nursing as profession behaves more like a loose confederation of warring tribes than a cohesive unit. Much as it pains me to say so, this is a direct result of a profession made up of females.

Women have then and now have various reasons for becoming nurses, and not all of them had anything to with "helping others". Like it or not nursing has always been viewed as an easy profession to pick up and drop as a woman's life situation warrants. This is one of the reasons historically given for not phasing out two year programs in favour of the BSN. Not everyone has the time or money for a four year college degree and or need to get into the workforce quickly, so the theory goes. If you mandate the BSN you'll be removing an option for much needed employment. Even the current administration is pushing "community college" degrees including nursing for those whom are under, unemployed and or displaced due layoffs and so forth.

Now I ask you when was the last time you heard about a "fast way" to become a physican because someone needs a job quickly?

Get out of my head!!!

I cannot agree more with you.

There really is no cohesive group within nursing because you are right, some people get into the profession looking at it as a life long profession, others have stumbled upon an easy in easy out job.

If the standards were raised and a four year degree was the standard then some of the more casual members would maybe be dissuaded from entering the profession.

When you hear the term physician you automatically picture an eight year degree with a residency. When you hear the term nurse you think what, maybe a year worth of tech school for some LPN programs and maybe a two year associate degree RN?

[DoGoodThenGo]

I agree with you and not in the way you think. I think the standard entry level nurse should be at the associate level scrap the LPN (yes even though I am one) and merge them into the role.. The BSN should equal having extra skills and knowledge not being some hodge podge of entry level and experienced nurses.

If you make the entry level nurse a BSN or higher your probably going to exacerbate the deskilling problem as staff becomes more and more expensive and less and less inclined to do hands on care.

So basic nurse = 2 year program which fits in which the educational infrastructure we have now. People in their cry to BSN only always fail to look at the fact that many nursing programs don't have the ability to phase up to that level since they are not at bachelor's degree issuing institutions.

Do the extra 2 years to get a BSN well that should be an extra endorsement to your license. Perhaps an extra exam maybe in a specialty. Make the BSN "mean" something more than a vague concept of moving into management

I think sometime we get caught up on ideals and ignore the practicality. We need to blend what we want with what the system needs otherwise they'll just invent a new title that will replace nurses entirely.

One of the problems is that as things stand now in all fifty states all three types of education allow one to become a RN upon passing the boards. Sadly a very good job has been done of making LPNs/LVNs seem barely above nursing assistants and not really professional nurses at all. Anyone proposing taking away future graduates of ADN or diploma schools right to use the title "Registered Nurse" is going to have a fight on their hands from several fronts.

The ANA learned this first hand when their white paper proposed making the BSN mandatory for entry to the RN practice and regulating diploma/ADN grads to "technical" or some other title nurse. Push back was prompt, swift and in short order let that body know that idea was a non-starter so they had better think again.

[Asystole RN]

Why would aides and techs feel "left out" of a nursing association? They are not nurses. On the other hand, we (LPNs) have every right to feel "left out" of the American NURSES Association.

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?

[Asystole RN]

I think your wrong on that point. The problem is that we have separate nursing bodies/unions that fight against each other. If we were in the same body it might be rough at first but things would be smoothed out and optimized eventually and yes the CNA's would be left out but it would be a nursing body so thats expected

In my state the LVNs and the RN's have different BON and that causes some problems.

I'm all for nationalized licensing maybe even get rid of the two titles and have a level system of education and licensing but I'm from a country originally that had that kind of system for all levels of education and titles.

But wouldn't in be great if we had a system where career advancement up the clinical ladder wasn't solely tied to your facility.

It would legally be extremely difficult to have a nationalized license due to Constitutional state's rights issues. You could theoretically have a nationally recognized state issued license, like an extended compact state agreement.

In my state the BON regulates RNs, LPNs, and CNAs.

Unfortunately, the goals of RNs is too different from the goals of LPNs. We compete for the same jobs...lol

If LPNs wanted to join a national nursing organization then why have they not created one? Maybe they have and I have not heard of it?

[DoGoodThenGo]

Given the current employment situation around most parts of the USA it is probably moot to even have a conversation about roles for RN and a two year "LPN/techincal" nurse as hospitals have already made their decisions. BSN preferred is the new mantra and that by default is pushing some many ADN grads into the few remaining areas where LPNs found refuge after being pushed out of hospitals.

The only LPNs one knows around here that have anywhere near steady gigs work as new mother/infant nurses.

[BrandonLPN, LPN]

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

Obviously "some" people are ignorant of what the 'N' in LPN stands for.

[Asystole RN]

Obviously "some" people are ignorant of what the 'N' in LPN stands for.

CNA

[DoGoodThenGo]

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?

It of course varies by state, but in NY for instance nursing assistants are not regulated and or issued a license by the same body that does so for professional nurses. CNAs are just that, they have been issued a certificate that indicates the fullfilling of certain educational and other requirements, but they do not have a professional license.

As for using the term "nurse", again it would vary by state but in NY any graduate of an accredited program is allowed to call themselves a "nurse" (graduate) and once properly licensed a RN or LPN.

[tothepointeLVN, LVN]

Well just because I want it doesn't mean all the other LPN/LVN want it too. Though to be honest getting out of dissatisfaction with the LVN role is a lot easier for us. Just become an RN. So in some ways we don't find our heads banging on the wall so much or if we do we are reassured of a path out of it if we want.

So if adding additional education and clinical hours equals an upgrade in license for a LVN/LPN moving up shouldn't a RN moving from ADN to BSN be offered the same reward in addition to a pretty thing to hang on the wall? Don't RT's have a two tiered system with RCP and RRT ?

And should RN's and LVN's be competing for the same jobs if we have two different SOP. Don't you think that working together would clarify that issue. Or is it because you as an RN don't have a desire to play nice and would prefer that skills be given to UAP rather than to an LVN because you feel we are competing somehow.

[tothepointeLVN, LVN]

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

Meh only by RN's who seem to have a misconception that extra year of school dramatically changes the way a nurse practices. Face it RN's feel threatened on all sides and instead of working collaboratively they lash out or make grandiose statements

[BrandonLPN, LPN]

CNA:no:

Oh come on, now you're just being silly. The job title of a CNA explicitly states that they are an assistant to a nurse. The job title of a RN and a LPN explicitly states that they are ARE nurses. This isn't an "opinion" anyone who says otherwise is just factually wrong.

[DoGoodThenGo]

CNA

There have been nursing assistants going back decades and they have never been considered professional nurses. Part of the healthcare/nursing team yes, but not nurses.

Certified Nursing Assistants and all the hype that seems to come from using those initials only came about when the federal government demanded some sort of central state registry and IIRC minimum standards for assistants to work in certain facilities receiving Medicare or Medicaid funding.

Prior to all this "CNA" business nursing assistants/orderlies and so forth may have stated such when queried as to their employment, but it wasn't elevated to the point of being a professional title. Of course one does not know everything and cannot speak for all of the USA but usually the only time you saw "NA" after a name was in charting and sometimes depending upon the facility not even then.