Are we deskilling

[XB9S, BSN, MSN, EdD, RN, APN]

I have had a really busy day today and as part of my job I am the nurse practitioner for surgical outlyers. We don't get them often but today we had a few on medical wards.

One of these patients was a bowel obstruction, distended, vomiting and poorly. He was going to be treated conservativly with IVI and NG tube. I got to the ward and the staff nurse informed me that his NG had come out, she was in the process of bleeping the doctor to put it back and there were no nurses on the ward who could put NG tubes in.

Now when I did my training we were taught to insert ryles tubes, is this no longer the case. I find it worrying that the doctors that she bleeped are house officers and haven't put NG tubes in (our surgical nurses do it) and there weren't any nurses that could do it. I did it which is fine but I wonder what happens tomorrow on my day off.

I worry that as nurse pracs we are doing these things but not allowing the ward nurses or new docs to learn because we always do them.

Not sure what the solution is, if I were a patient I would want the most experience person doing things like that for me but we all have to learn sometimes. I do try to teach when I do these things but the nurses on the ward today weren't interested, as far as they were concerned they hadn't done a course to put NG tubes in so they wouldn't do them (OUr trust doesn't rund a course by the way)

Not sure what my point is, I know I am rambling a bit, but I do wonder (and maybe Ayla can answer this) is nurse education lacking in clinical skills, is this the sort of thing we should be learning in nursing school and encourage our students to be doing and do we really need a study day to be able to put a naso gastric tube in? (or catherise for that matter) or is this something that should be covered in nursing school.

ANy thoughts from anyone else

[MaryAnn_RN]

Deskilling is a very real issue. I worked with a staff nurse a couple of years ago who asked me to catheterise her female patient - she claimed not to have done it before but had been qualified for several years. I didn't do it for her, I taught her to do it. We have patients stuck in the HDU for days because the respiratory care unit 'doesn't do bipap/cpap'. Lately the wards are extremely reluctant to have anyone with a trachy, although that might be to do with staffing as much as skill mix etc. Very recently we had a patient admitted to the ICU with ryles tube in his lung as seen on x-ray; he had 3 litres of bile aspirated from his stomach when the tube was replaced. How exactly tube placement was checked I don't know.

[XB9S, BSN, MSN, EdD, RN, APN]

Mary now you mention it Trachys are another problem we encounter, we now only have 2 wards that accept trachys in the hospital one surgical and one medical.

What can we do to overcome this?

[Silverdragon102, BSN]

I think in some cases with the work load we are deskilling. I remember we wasn't allowed to practice inserting NG tubes on each other but 2 of the tutors showed us by doing it on each other and I know I have passed many, the only ones I couldn't pass where NG tubes if feeding as policy of hospital was someone who had been on a course. I have no problems learning new skills if it will assist in my patient care but at the same time I don't want to be kept being pulled away because I could do it when others couldn't and also if generally staff not available to be able to give adequate nursing care.

[5cats]

I also believe Nurses are deskilled. But I must admit I'm only in the UK for 2 years now and received my basic education in Germany and further education in Switzerland. So my point of view might differ.

When I compare my basic education and work afterwards and the training nurses here receive nowadays, I'd say we need to change their basic training. Skills that you need nowadays on a ward should be included and practised during the training, it shouldn't be necessary to train everybody after they graduated. That includes catheterization, cannulation, sc im and iv, oral and ng drug application and many more skills.

When I'm watching the students, many seem to just observe and read their books. I think when they are on a ward/unit wherever they should practise what they learned before in theory under observation.

Staffing is another issue, a big issue, but doesn't exlain all of the things that are happening daily.

Just my thoughts.:icon_roll

5cats

[RGN1]

I think it all comes back down to the training issue again. We spent twice as many hours on the wards when I was training than the current Uni hours. We had more time learning practical skills & less time learning fluffy psyche-social things. NOT that they're not important but quite frankly I'd rather have a nurse who could do stuff for me than talk nicely to me! You can actually learn communication skill a lot quicker than you can practical stuff. A couple of researched essays during placements & that bits done! OK I'm dulling that down a bit but you get my drift.

I've only been in Canada a few weeks & am on a ward catering for far sicker people than I'm used to but the constant repition of newly accquired (or newly resurrected) skills means that every day my competency to care for those ptaients has increased & that's after only a relatively short time. I've learned trache care, male catheterisation, can manage triple line pumps, TNA feeding & have inserted Ng feeding tubes etc etc etc etc all in about 4 weeks.

Imagine what a student nurse could learn there in 3 months?? Now imagine what you could teach students if they were properly placed on your ward, with their classroom time actually spent backing up your teaching? Then think of the staff nurse that could result?

I say get students back out the classroom & properly on to the wards before it's too late! The students I had prior to coming out here had one constant moan - too much wishy-washy theory & not enough ward time - & none of this namby-pamby supernumery stuff either - that's rubbish. :-D

Just my opinion of course - that's what this forum is for - but I bet there's a fair few who agree or at least partly agree with my basic sentiment.

[cariad]

nursing in the us is a bit like canada, we do just about everything on the floor, and the techs,,,which is cna with a bit more inservice training catheterise both genders, and do lots of stuff that nurses back home do. they have a lot less education here to become a nurse, but once on the floor learn whatever it takes to look after your patient. nurses in the uk are a bit reluctant do things they havent done before and insist on inservices for it, but at the end of the day, once you have the knowledge,,,you have to do it to learn it.

[ZippyGBR, BSN, RN]

'de skilling' or 'recognsing the limitations of your own practice ? '

there is also the habit of a some doctors to write random orders for catheters and NG tubes...

we had a probem with a surgical doctor on the middle grade rota ( but not in a SpR post) who used to demand NG tubes and catheters on patients where the justification was slim to none existant...

she got a shock one morning when one of the consultant surgons took her aside and pointed out that acute surgical patients don't need a NG tube unless they are obstructed and nauseated becasue of the risks associated with trying to pass them ( he had by his own admission ' nearly killed someone' through a combination or over euthusiatic insertion and vagal nerve stimulation )

NG tubes are not pleasent to insert and as there's fewer and fewer NGs put in for feeding ( vs PEG etc.) it;s a procedure we do less and less ... another exmple of things moving on and moving away is gastric lavage .. talk to older A+E nurses and they used to do them on a regualr basis in unanaethetised patients , where as now it;s a once a year thing and the patient has to be anaesthetised ...

Nursing in the uk needs to get over itself with mal catheterisation - male cathetrisation unless the patient has known urologicl pathology is really quite simple as there's little or no chance of 'wrong hole' and other such shenanigans as as see nwith female catheterisation

[XB9S, BSN, MSN, EdD, RN, APN]

'de skilling' or 'recognsing the limitations of your own practice ? '

there is also the habit of a some doctors to write random orders for catheters and NG tubes...

Zippy I understand what your saying but passing a nasogastric tube used to be part of nursing practice when I qualified, you would never dream of asking a doctor to pass an NG tube but now I find there are more nurses who can't pass them than can. So my question would be as nurses in the UK are we losing our skills, not individually but as a collective.

(Also where I work if there was an inappropriate order for a nasogastric tube or catheter the nurses would question and refuse.)

[karenG]

I would agree that we are deskilling and losing the basic nursing skills of actually caring for patients!

my MiL is a patient in a care home, she cant walk following a stroke and her family couldnt care for her at home (and trust me, we tried). she has a massive pressure sacral pressure sore. In my day (pass me my zimmer) we would have be hung up and skinned alive slowly with a blunt knife for allowing this..

I've got an 18 yr old girl with foot drop following a hospital stay.. I've got patients with sores on heels and elbows following hospital stays..

now call me old fashioned but we did 2hrly back rounds when every patient recieved care, we changed beds, cleaned lockers, did pressure area care and talked to our patients while doing it. the ward sisters took part- they said it allowed them to get to know patients. I know care has changed but when working as a community matron, I would visit 'my' patients, and I was horrified to find a weeks worth of medication on lockers, leg ulcer dressings not done (because no-one knew how to do a leg ulcer dressing!) and patients unwashed and generally looking unkempt. Now I know its in part a staffing issue- there just arent the nurses on the wards to do the stuff that needs doing. But.. giving a hypertensive patient their medication and leaving it on the locker for them to take later, thats so wrong on so many levels!

oh and whats happened to stuff like good old fashioned mouth care??

we need to make the training more practical. I remember when a degree nurse would be greeted with scorn because they didnt know anything! those of us who trained the hard way (9 weeks in school then onto the ward to become part of the workforce!) thought degree nurses stupid when they asked what the crash trolley was for! and they did ask...

I dont know how you get round it.. the training needs to change. oh and we learnt how to pass ryles tubes on each other- ugh! so yes, I think nursing is becoming deskilled as we strive to get recognition as a profession. we should be careful we dont move too far away from what actually are.. we are nurses and even though I am now an advanced nurse practitioner, at the end of the day, I'm a nurse with a couple of fancy degrees and I could, if push came to shove, still run a ward and still do all the old fashioned care....

[ZippyGBR, BSN, RN]

I would agree that we are deskilling and losing the basic nursing skills of actually caring for patients!

are we or is down to the systems that Senior Nurses have allowed to be implemented ?

my MiL is a patient in a care home, she cant walk following a stroke and her family couldnt care for her at home (and trust me, we tried). she has a massive pressure sacral pressure sore. In my day (pass me my zimmer) we would have be hung up and skinned alive slowly with a blunt knife for allowing this..

nursing or residential ? that said Nursing homes generally provide little in the way of nursing as the RN : resident ratios are very poor even on days ...

I've got an 18 yr old girl with foot drop following a hospital stay.. I've got patients with sores on heels and elbows following hospital stays..

part of the problem is the fact that on the vast majority of wards staff are afraid to be 'assertive' in getting patients up , out of bed and so on as their condition allows , there;s also the risk that you will be disciplined on the basis of a complaint made by a patient, relative or HCA

which the incompetentn idiots promoted out of harms way will use aginst you for the next however many years and keep reminding you 'how lucky you are to have kept your job '

now call me old fashioned but we did 2hrly back rounds when every patient recieved care, we changed beds, cleaned lockers, did pressure area care and talked to our patients while doing it.

but people were also unnecessarily kept on prolonged bed rest, admitted unnecessarily early for procedures and various other issues ...

the ward sisters took part- they said it allowed them to get to know patients. I know care has changed but when working as a community matron, I would visit 'my' patients, and I was horrified to find a weeks worth of medication on lockers,

this is unacceptable, but a mobile, mentally competent patient cannot be forced to take medication. and standing over them 'strongly encouraging' them to do so again puts you at risk of a complaint which the clueless bleeding heart s in PALS will take at face value and encourage the dangerous muppet who has been promoted out harms way to turn into a full disciplinary

leg ulcer dressings not done (because no-one knew how to do a leg ulcer dressing!)

so you want people who are not comeptent to do 4 layer compression bandaging ? you also need to consider the fact that when joint formularies are agreed the community TVNs place horrific warnings aobut having completed the official training for four layer bandaging before even touching them ...

and patients unwashed and generally looking unkempt.

again mobile and competent patients, even those immobile and competenet have the right to refuse and to force it is assault

oh and whats happened to stuff like good old fashioned mouth care??

again if a competent patient refuses what exactly are you meant to do ?

we need to make the training more practical.

the EU directive that governs pre-registration Nurse education already specifies 2300 hours of clinical placements whch constitutes half of the pre-registration training timetable, plus any time of the 2300 hours that the HEI spends on teaching practical skills and doing simulation / scenarios etc

I think nursing is becoming deskilled as we strive to get recognition as a profession. we should be careful we dont move too far away from what actually are.. we are nurses and even though I am now an advanced nurse practitioner, at the end of the day, I'm a nurse with a couple of fancy degrees and I could, if push came to shove, still run a ward and still do all the old fashioned care....

de-skilled or re-skilled ?

there is an almost Amish tendancy among some Nurses to set a point which was the self set 'zenith ' of nursing practice and changes before then ( i.e. Nurses undertaking Blood pressure recording, Nurses monitoring IV infusions , nurses giving SC and IM injections ) are acceptable but changes after are unacceptable ...

there's variation just like there's different sub groups of amish some who won't use a phone at all, some who will use a payphone in the townor at the store, through others who consider it acceptable ot have your own phone booth on your land through to those who will have a dial phone in the porch ...

what you also have to remember is that the culture over reporting things in acute care has changed, so HCAs and domestics anow feel it's entirely approrpaite to shoot first and ask questions later when reporting RNs for 'assaulting patients' and never mind the fact the patient is filthy or has just put themselves or others at risk of physical harm ... is it any wonder that Ns fear from being stabbed i nthe back by staff ... we've not even mentioned the trust's professional meddlers in the fom of PALS who start their own investigation and the staff member and the ward manager know nothing until thematron and the HR Manager come and 'arrest' the member of staff in the middle of the ward

[karenG]

oh dear, I think I upset you!! apologies as I didnt mean to upset anyone!

are we or is down to the systems that Senior Nurses have allowed to be implemented ?

fair comment; I've been on of those senior nurses as a lead nurse. we have no control over the training of students and I think part of the problem lies with the training and the expectations of student nurses. I was lead nurse for the local Primary care trust so my role was community based. we had problems with new nurses coming to work in the community with little or no basic nursing care knowledge.

nursing or residential ? that said Nursing homes generally provide little in the way of nursing as the RN : resident ratios are very poor even on days ...

she is in a nursing home which has a matron and several staff nurses, a few hca's (who are excellent). my argurment with the home is they allowed this to develop and only acted to do anything when it was big enough to put my fist in the hole. surely someone who was getting her up and caring for her would have noticed the sore long before it reached that stage

part of the problem is the fact that on the vast majority of wards staff are afraid to be 'assertive' in getting patients up , out of bed and so on as their condition allows , there;s also the risk that you will be disciplined on the basis of a complaint made by a patient, relative or HCA

which the incompetentn idiots promoted out of harms way will use aginst you for the next however many years and keep reminding you 'how lucky you are to have kept your job '

this is how the role has changed. you need to be assertive at times.

but people were also unnecessarily kept on prolonged bed rest, admitted unnecessarily early for procedures and various other issues ...

yes true in some ways,we did admit people early and yes they were in for a while after surgery etc. But actually no, we didnt keep people on bed rest that often- they were encouraged to be up and mobile asap. for me working in the community, I would say in some ways people are discharged too soon- we see lots of people post surgery who are having problems because they came home the day after and are not coping with the pain or the movement restriction.

this is unacceptable, but a mobile, mentally competent patient cannot be forced to take medication. and standing over them 'strongly encouraging' them to do so again puts you at risk of a complaint which the clueless bleeding heart s in PALS will take at face value and encourage the dangerous muppet who has been promoted out harms way to turn into a full disciplinary

these are not not mobile patients- community matrons dont manage fit healthy people! my work load was of mainly people with copd and co-morbitity such as diabeties. not sure how this arguement would work if the patient had a cva while in hospital. or where you would stand should a 5yr old visitor swallow grannies pills because the nurse had left them on the side. surely it would be better to record refused on the record and remove the pills?? though in my day (zimmer again) patients didnt refuse!

so you want people who are not comeptent to do 4 layer compression bandaging ? you also need to consider the fact that when joint formularies are agreed the community TVNs place horrific warnings aobut having completed the official training for four layer bandaging before even touching them ...

I want my patients to recieve a basic level of nursing care. and I'm sorry, if its a medical ward then someone should be able to do 4 layer bandaging or if you cant do that, short stretch bandages. if thats not possible, is there not a wound care nurse who can? this is not rocket science. Also, not all leg ulces have 4 layer banages.. some have simple stuff like hydrocolliod dressings. can they not be changed?? (actually my experiance is that they cant).

de-skilled or re-skilled ?

there is an almost Amish tendancy among some Nurses to set a point which was the self set 'zenith ' of nursing practice and changes before then ( i.e. Nurses undertaking Blood pressure recording, Nurses monitoring IV infusions , nurses giving SC and IM injections ) are acceptable but changes after are unacceptable ...

there's variation just like there's different sub groups of amish some who won't use a phone at all, some who will use a payphone in the townor at the store, through others who consider it acceptable ot have your own phone booth on your land through to those who will have a dial phone in the porch ...

what you also have to remember is that the culture over reporting things in acute care has changed, so HCAs and domestics anow feel it's entirely approrpaite to shoot first and ask questions later when reporting RNs for 'assaulting patients' and never mind the fact the patient is filthy or has just put themselves or others at risk of physical harm ... is it any wonder that Ns fear from being stabbed i nthe back by staff ... we've not even mentioned the trust's professional meddlers in the fom of PALS who start their own investigation and the staff member and the ward manager know nothing until thematron and the HR Manager come and 'arrest' the member of staff in the middle of the ward

oh dont worry, patients report us out here in the community too. we get complaints about not doing stuff or doing stuff they didnt want etc. dammed if you do and dammed if you dont.

change is inevitable and I'm glad I didnt train when my mum did- she spent the first year of her training learning how to clean cupboards. I accept that my training was different to current models of training. But I am a clinical practice teacher and I am involved in training nurses both undergraduate and post graduate. I do believe that just maybe the training has swung away from caring for patients and moved to a more academic level. there are some things I think a nurse should be able to do and yes, some are basic like taking a bp.. tell me- what happens when all the electronic bp machines breakdown.. can anyone still use an old fashioned sphyg?? I think being able to do simple stuff like pressure area care/mouth care (patients do need it still when unconcious- never seen it done though and the students I meet have no idea!) and maybe just listening to patients is being lost.

we need to go back to basics sometimes and build from there. we need more staff to deal with patients. more resourses. better access to courses.. and some recognition for the job we actually do.

I'd like to stop the infighting.. and for us to support each other more. I'd like hospital nurses to recognise that those of us out here in the community are here because we want to be, and that we are nurses too! I'm just a bit fed up of being told what I should prescribe my copd patients by a staff nurse who is wet behind the ears (I've an msc in respiratory medicine). I acknowledge that there are very good hospital nurses and you work damm hard with little support. there must be some way for us to support each other and recognise each others worth.

will get off my soapbox now and see some patients..