Are we deskilling

[XB9S]

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

[ZippyGBR, BSN, RN]

karen G - you didn't upset me ... i'm less than happy with the way in which we let some of the acute areas i run , in fact one of the reasons i am working where i work at present was due to a combination of an utter lakc of support and poor management on the unit where i was working, that resulted in me having to take time off sick before i became genuinely mentally ill and in writing one of the most scathing letters i've ever written to a professional colleague ...

there are two things that really annoy me the stuff i described as the 'amish' stuff and those who won't accept that staff on areas which offer placements have an equal share in preparing students for clinicla practice ....

the next closest annoyance is the way in which senior Nurses especially ( hospital based )matrons roll over to lay managers far too easily and also fail to remain involved in clinicla practice unlike community matrons, Doctrs as managers, midwives as managers and AHPs as managers

[cheshirecat]

Have to say that the wards karen G talks about are nothing like the wards of today.

When I first qualified (1985) I worked as a staff nurse on a surgical ward. Our hernia repair patients would stay in 5 days post-op, APR resections would come in for 5 day bowel prep etc. So we had many more 'well' patients then we do today.

On the surgical ward I worked on until 1.5 years ago, a good day looked like Beirut(hope thats spelled right).

We had 1 RN for 16 patients, supported by 2 HCA'S. No enrolled nurses to take some of the burden from the RN. Students used as HCA's and no time for training. This is why we are getting newly qualified nurses who cannot do s/c, im injections, cath patients, put in ryles tubes etc. It is because they are being used as HCA's and not given the training they should be getting.

We are all guilty of this in my mind. We should as a profession stand up to our managers. We should demand more staff so we can teach students.

And if we have to go on strike to get this? I would, would you.

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

CC I understand what your saying but when I trained we were counted in the nursing numbers, so we also did the work of the HCA'a and managed to get the clinical skills that we needed. I know that the ward environment has changed and the patients are sicker but I am not convinced that this is the reason why.

I notice that both Zippy and yourself have blamed managment, and I find this difficult as well as I am classed as management in my role, I do have clinical days but I work as part of the managrerial team as well.

I fight tooth and nail for the nurses on my wards, and push for improvements in patient care in which I have had some huge successes. I am not saying that there aren't some poor managers out there, but I have been very lucky where I work as I have some excellent managers who support the staff with what they want and need.

As a little side note, the ward I went to see this patient on had 5 nurses and 3 health care support workers for 19 patients - I was told this is usual staffing levels for that directorate, and remember that this isn't one of my wards they were sat at the nursing stating drinking tea (don't start me off on the infection control issues around that) chatting and not one of them offered to help me find the stuff I needed or help me with the patient who vomited everywhere and needed to be cleaned before the tube went in, I did that myself and that's fine because I don't mind but they didn't offer to help which annoyed me. It would have been a perfect opportunity for one of them to learn how to put an NG in, I was willing to teach but the attitude I got back was they didn't want to learn.

[karenG]

As a little side note, the ward I went to see this patient on had 5 nurses and 3 health care support workers for 19 patients - I was told this is usual staffing levels for that directorate, and remember that this isn't one of my wards they were sat at the nursing stating drinking tea (don't start me off on the infection control issues around that) chatting and not one of them offered to help me find the stuff I needed or help me with the patient who vomited everywhere and needed to be cleaned before the tube went in, I did that myself and that's fine because I don't mind but they didn't offer to help which annoyed me. It would have been a perfect opportunity for one of them to learn how to put an NG in, I was willing to teach but the attitude I got back was they didn't want to learn.

reminds me of the day I was shadowed by the chief exec of the pct.. she wanted to know what community matrons did! we walked onto a ward to see a couple of patients and the ward sister stood at one end of ward and bellowed at me 'what the ******** 'ell are you doing 'ere??'. to say the chief exec was not impressed is putting it mildly!!

[RGN1]

With nurses being expected to take on more advanced roles this is where CNA's/HCA's (or whatever you call them where you are) should be trained to step into the breach. I don't think we should be training them to do our vitals/obs, catherisations, or NG insertions etc! They should be there to carry out the personal care that we are no longer able (I say able, not willing, for a reason) to do.

Right now I'm lucky if I can get an aide to get so much as a glass of water for my pts! I'm trying to "encourage" them ( with some success I have to say) but they are as consfused about their roles as we are right now! Their mandate should be personal care, end of story. They should be there to assist with washes, repositioning, toileting, feeding etc. Thus freeing up the nurse to proplerly assess her pts & carry out prescribed treatments etc.

Nursing has changed from the "back round" days - & yes, I did those too - so I'm talking from experience!! However, you couldn't possibly do that now with the workload we have at present BUT you could easily train a team of CNA's/HCA's to do that side of nursing care. After all it was actually the student nurses (at least when I was training) who did that care before, slowly "graduating" up, for want of a better phrase, as they progressed through their training.

We can't go back but we have to go forward in a way that benefits our pts best. I don't think unqualified personnel should be carrying out any tasks that are invasive or require assessment choices but I strongly feel that they should be carrying out the personal care when we can't.

I'm not talking about passing the buck either, it's purely a matter of a shift in workload that's not my choice but is how it is. However, if you have time to chat & drink tea at the nurses station then you can help too!! I can't bear to hear stories ogf nurses behaving like that, If I have any spare time I go & chat to my pts, it's amazing what you can learn by doing that!

Ultimately though, I still stick by my very first comments on my earlier posts - that students should be back on the wards, as they were before, because then you have a band of ready made staff to teach, who are there to learn & to help!

[RGN1]

reminds me of the day I was shadowed by the chief exec of the pct.. she wanted to know what community matrons did! we walked onto a ward to see a couple of patients and the ward sister stood at one end of ward and bellowed at me 'what the ******** 'ell are you doing 'ere??'. to say the chief exec was not impressed is putting it mildly!!

:eek:

[Zana2]

Hmmm, the lack of skills...

the 2 main reasons why I haven't got many, and I'm in my 3rd year, are: the placements are too short (1 month) and we're being used as HCA's due to the lack of staff.

I am now looking to get a job in..anything, really, that has got a good new grad program. I know I don't know. I know it's going to be my pin at stake and i'm willing to get any job that would teach me.

I don't lack initiative. I look up 'what is it that that ward does' and I ask my mentors:could i learn this, that and the other? The outcome is: the staff hasn't got the time to teach me, form a team with your mentor and she does the clinical stuff, you do the hca's stuff, it's the only way you can help her. In return, she helps you by signing all that stuff that says your attire is appropriate, you respect the NMC, you were a team member. Next!

[MaryAnn_RN]

I was about to write all the times I offered to teach students this that and the other. Here is one example.

A couple of weeks ago, had a very complex, very unstable patient who had to go to CT along with 2 anaesthetist, myself, 2 porters blah blah blah.

I really thought it would be interesting for them to see what was going on..."No thank you, we've done that" was the answer.

[cheshirecat]

Back in the bad old days, students were taught by students. As a first year on the wards, I would not even talk to a Staff Nurse. A third year used to take you under her wing, and show you how to do things. As you progressed through the years you became the teacher.

Our hospital used to be staffed by student nurses. They where the workforce. On an early shift there would be 1 staff nurse, maybe 2 3rd years, 2 2nd years and 2 1st years.

I think the students today get a raw deal. They are used as unpaid workers. At least we got a wage at the end of the day.

I can understand students not wanting to wipe up **** etc if they are being paid nowt. Also, if they are not being taught anything on the ward, why should they put themselves out?

[ZippyGBR, BSN, RN]

CC I understand what your saying but when I trained we were counted in the nursing numbers, so we also did the work of the HCA'a and managed to get the clinical skills that we needed. I know that the ward environment has changed and the patients are sicker but I am not convinced that this is the reason why.

the average acute ward now is seriously and acutely ill patients ... the delayed discharges are housed on the delayed discharge unit and anyone remotely near well is either home or aobut to be discharged home from AAU / CDU / short stay ....

I notice that both Zippy and yourself have blamed managment, and I find this difficult as well as I am classed as management in my role, I do have clinical days but I work as part of the managrerial team as well.

the biggest problem lays with Ward Managers who are unable to relate to lay managers and Matrons and ADoNs who were promoted out of troulbe from being ward managers and now they are over 50 years of age too expensive to make redundant so have to be kept in management roles as they can't be moved to clinical roles as their clinical skills are extremely poor ... I've had more clinical help from (lay person) directorate managers than from the majority of (acute sector) matrons i've met - often becasue the lay manager has no fear of saying ' i have no clinical skills , but i'll porter /make beds / help serve dinners ...)

I fight tooth and nail for the nurses on my wards, and push for improvements in patient care in which I have had some huge successes. I am not saying that there aren't some poor managers out there, but I have been very lucky where I work as I have some excellent managers who support the staff with what they want and need.

i'll tell you ar story about that there is someone i had the misfortune to be managed by who despite her very public claims from an extra curricular activitiy about supporting safe staffing and wfighting to maintan skill mix sold that out for a lead Nurse role and saw the majority of a departments staff leave many voluntarily and 10 band 5s and none navy blue band 6s redeployed to be replaced by HCAs ... the problem being the rest of the none navy blue band 6s after being told that they were not wanted becasue they were too expensive upped sticks and moved to a neighbouring trust that did want them decimating the department and leading to serious problems in service delivery ...

[ZippyGBR, BSN, RN]

I think the students today get a raw deal. They are used as unpaid workers. At least we got a wage at the end of the day.

students are not 'unpaid workers' for the following reasons

1. if this were the case the placement area would be pulled

2. students should not replace staff once the minimum acceptable staffing for an area is reached

3. these 'unpaid workers' get their bursary gross s well as the other advantages of being a full time student e.g. council tax exemption / reduction ....

then there's all the other allowances that would not be legla should we return to students being paid

[RGN1]

Hmmm, the lack of skills...

the 2 main reasons why I haven't got many, and I'm in my 3rd year, are: the placements are too short (1 month) and we're being used as HCA's due to the lack of staff.

I am now looking to get a job in..anything, really, that has got a good new grad program. I know I don't know. I know it's going to be my pin at stake and i'm willing to get any job that would teach me.

I don't lack initiative. I look up 'what is it that that ward does' and I ask my mentors:could i learn this, that and the other? The outcome is: the staff hasn't got the time to teach me, form a team with your mentor and she does the clinical stuff, you do the hca's stuff, it's the only way you can help her. In return, she helps you by signing all that stuff that says your attire is appropriate, you respect the NMC, you were a team member. Next!

This just about sums it up doesn't it? I had a student who was on p[lacement for 1 month - what the Uni thought she could acheive in that time was totoally ridiculous. Also every placement is in a new hospital, it can take that time just to learn new paperwork!!

I wrote that on the assessment pages of her workbook & told the uNi they were being unfair to their students but it fell on deaf ears - I just got the -"complete the competencies" spiel from them. many pof the competencies I marked as "discussed" because we couldn't hope to acheive them!

Another student was on placement with us but at Uni was doing her child health module & essays - how ridiculous!! Nothing seems to relate anymore! When we did surgical nursing we were on surgical wards & so on!!

Zana, I'm sorry the system has let you down but I have been fortunate to work with many students who were good & tried their best to learn despite the system & I'm sure you'll be/are one of them!!

Interestingly here in Canada students have what I can only describe as clinical nurse tutors come to the wards & work with them (hey guys who remembers those??? We had to prove we could do certain competencies like aseptic technique to our clinical tutors before we could pass our modules!)

Undergrad nurses (final year I believe, although I haven't worked it out quite yet) can work pretty much as our old EN's on the ward as paid bank staff - they give meds & take their own pts but can't do some things like hang TNA/TPN or change PCA meds.