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.'
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.Last edit by Joe V on Jan 8, '15
About TheCommuter, BSN, RN Moderator
TheCommuter is a moderator of allnurses.com and has varied experiences upon which to draw for her articles. She was an LPN/LVN for more than four years prior to becoming a registered nurse.
Joined: Feb '05; Posts: 38,035; Likes: 69,338
CRRN, now a case management RN; from US
11 year(s) of experience in Case mgmt., rehab, (CRRN), LTC & psychAug 25, '12I don't want to mix my own drugs. With all of the paperwork/charting on top of the nursing care, I wouldn't have time, and am glad pharmacy does this. We don't have any CNA's, and we draw all our own labs in my ICU (which is typical in ICU's), so I guess this article really isn't applicable in that setting.
But, I can see how it is applicable almost everywhere else. I see what you're saying, but I still think nurses are valuable, and the skills that are being taken away from us are not rocket science. Anyone can d/c a peripheral IV or urinary catheter, though I do think that only nurses should be inserting foley catheters.
I do also think that only RN's and LPNs should be allowed to administer medication. I don't think a medication tech has the knowledge base to administer them safely. A lot goes into administering meds, knowing the side effects, their use, when to hold them, and especially in the poly-pharmacy world that is geriatrics, it is unsafe. This can only be taught in since one pharmacology course does not cover this; you need to understand human physiology to know why certain meds need to be given and others held.Aug 25, '12Although the typical shift of the bedside nurse is already busy enough, and even though the skills that have already been removed from nursing are not the most complicated, this issue is problematic.
Why should we be concerned? If there's even one unemployed nurse in society who desperately wants to work, then the de-skilling of nursing has become out of control. We need to stop blowing this issue off for the sake of the unemployed new grads and jobless experienced nurses who would kill to be working.
Jobs that could be performed by licensed nurses (RNs and LPNs) are being done by others. This means that one nurse out there is jobless while some technician, medication aide, therapist, or phlebotomist out there gains a job.Aug 25, '12Nursing has been de-skilling for many decades... respiratory therapy , nutrion, PT & OT were once part of the RNs role. On the other hand nurses have added skills that were once the performed by MDs only. The question is balance, I don't mind loosing skills if I am gaining (for lack of better term) more advanced skills and commensurate compensation for those skills.Aug 25, '12Great article (as usual)! The physical therapists doing wound care is concerning to me. I understand having techs do some skills, and medication aides, from a cost perspective; phlebotomy makes sense, in that way; but now that PT's have to have a doctorate, how does that at all make sense since we have WOCNs that do wonderful work? The first time I saw this, it was a PT that came in to my (back in my med surg days) primary patient's room every day to do this pulse lavage treatment that was pretty new at the time. It just seemed like a way for their department to generate revenue. Didn't benefit the patient. Maybe because "nursing services" come just, you know, bundled in the room payment.Aug 25, '12Quote from hey_suzYes. My place of employment (an acute rehabilitation hospital) has a wound care team that consists of physical therapists and occupational therapists who can bill and charge for every dressing change, ACE wrap, wound vac application, and every type of simple and complicated wound care treatment possible.. . .but now that PT's have to have a doctorate, how does that at all make sense since we have WOCNs that do wonderful work? The first time I saw this, it was a PT that came in to my (back in my med surg days) primary patient's room every day to do this pulse lavage treatment that was pretty new at the time. It just seemed like a way for their department to generate revenue. Didn't benefit the patient. Maybe because "nursing services" come just, you know, bundled in the room payment.
From a monetary perspective, the PTs/OTs generally earn higher salaries and can bill for wound care services when a certified wound care nurse could accomplish the same tasks in a more cost-effective manner. Just another nursing job being displaced...Aug 25, '12What I went to school for is different from how I get to actually practice at my work. I feel like I'm handing out meds and doing treatments more so than the things that would actually increase my patient's wellness. It is cost-effective to have 2 CNAs for 1 nurse, but it's not helping the patient gain much in the way of long-term wellness.Aug 25, '12Nursing is making their own bed. The efforts to "elevate" the profession are what's downsizing it.Aug 25, '12Quote from ocankheAlso, obstetrics was once within the strict realm of nursing (midwifery). Even though nurse midwives still exist, obstetrics and childbirth have been taken over by physicians due to a widespread smear campaign against the nurse midwifery profession during the last century.Nursing has been de-skilling for many decades... respiratory therapy , nutrion, PT & OT were once part of the RNs role.
Quote from ocankheI'll agree that nurses are gaining a handful of more advanced skills. However, we are also gaining more accountability without the corresponding authority. We are also entering an era of stagnating and/or deflating nursing wages.On the other hand nurses have added skills that were once the performed by MDs only. The question is balance, I don't mind loosing skills if I am gaining (for lack of better term) more advanced skills and commensurate compensation for those skills.Aug 25, '12Quote from ocankheI 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.Nursing has been de-skilling for many decades... respiratory therapy , nutrion, PT & OT were once part of the RNs role. On the other hand nurses have added skills that were once the performed by MDs only. The question is balance, I don't mind loosing skills if I am gaining (for lack of better term) more advanced skills and commensurate compensation for those skills.
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.Aug 25, '12Quote from woohToo bad we couldn't bill for each call light answered.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.Aug 25, '12I have said on many occasions.....we are going to educate ourselves out of the bedside if we keep insisting that "isn't a nursing duty". I have worked in ICUs that I draw all labs and EKGS and I have worked in ICUs that those tasks were done by someone else.
When I started nursing in the ICU we did it all. We mixed our meds, did our own labs, mixed our own gtts and "Hyperal" We had to be very specially trained to be there and our patients needed very specialized care. We may not have had all the "fancy equipment" but we had vents, balloon pumps, temp pacers, and gambros. Our MI's had all the arrhythmias because we didn't intervene. Inferiors had Brady's and heart blocks...your anteriors Vtach/Vfib. If they developed a murmor......we called the MD......they weren't going to do well.
We trialed the new meds....hung IV nitro, TPA, IV bretylium....... for the first time. I have seen and cared for the first "artificial heart" LVADS that turned into the portable LVADs ........I have practiced through medical history. Our calculations were by hand. I remember the first computers installed, the first printer for lab results....that was a great day. I am highly trained, very well educated.....at the bedside not with degrees.....I am extremely specialized the MD's depended on me. It was the nurse at the bedside that did all these things.
Now, If they can find someone else to bathe, assess a patient from a TV monitor in a remote location, read my strips, change me dressings, watch my balloon pump, run my gambro or ECCMO...... fix my drips or pass my meds...... what will they need me for?
That will be a sad day.Last edit by Esme12 on Aug 25, '12Aug 25, '12Nurses, you have made your bed, and are now suffering the results of it.
Nurses need to belong to a powerful national union to protect our best interests. By refusing to organize years ago, we have surrendered our professional identity and practice to hospital administrators,who would like nothing more than to be able to run a hospital with as few nurses as possible. I have heard all of the views against unions, but reality is, with no national union/organization to represent OUR BEST INTERESTS, we will ALWAYS LOSE OUT TO THE INDIVIDUALS WHO DO HOLD THE POWER!!
Nurses, you cannot speak for yourself when it comes to issues like this. You are out gunned, and out spent by the ptb, who have their best interests in mind $$$$$, not yours.
I will say it again, nurses need to join the National Nurses United, and become a force to be reckoned with. Without it, nursing will cease to exist as it is now, in a generation. It is already happening.
Our professional practice is being sold to the highest bidder. When did it become a funcion of PTs and OTs to do dressing changes? They do not learn sterile technique in school, and nurses do. Their professional organizations are being proactive in ensuring that they have billable skills to add $$ to the hospital. Especially since they have gone to a doctorate and masters degree as entry into practice. As long as a nurses professional practice is rolled into the room rate, housekeeping, and complimentary roll of toilet paper, nurses will always be an expense, instead of an asset to the hospital.
Why should RTs charge to do ABGs? I did them in the ICU, and was not able to bill for them. But the RTs did. Again, another instance of RTs making themselves valuable to the hospitals. It is called job security, and nurses have not learned that skill.
WAKE UP NURSES, OR WE WILL NOT BE AROUND FOR MUCH LONGER!!
JMHO AND MY NY $0.02.
Lindarn, RN, BSN, CCRN
Somewhere in the PACNW
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