Stop the (Deskilling) Merry-Go-Round, I Want to Get OFF!

NotReady4PrimeTime, RN

Alternative title (courtesy of Brian Booth): How much is that cheap thing you bought going to cost you in the long run?

Once upon a time, the Powers-That-Be, residing in the ivory towers of academe, decided that nurses should be considered professional providers of health care. The main flaw in the situation at the time was the definition of professional, which implied university preparation with perhaps some advanced education on top... and too many of the "professionals" in the nursing field had been educated through hospitals or community colleges so were therefore not entitled to call themselves professionals. These lesser souls had been trained in the necessary skills to provide excellent care to their patients, but lacked the liberal arts education deemed essential to professionalism. And so the baby was thrown out with the bath water, a university education was declared the minimum for entry to practice as a professional nurse and much money changed hands.

The further from its roots nursing moved, the less it seemed the skills of patient care mattered. After all, professionals command professional remuneration, and no one wants to pay any more than they have to for things like washing bottoms. Besides, professional nurses have the documentation that indicates they have the education to supervise and manage bottom-washing.

So again the Powers-That-Be got together, determined to uncover methods of economy for the care they were required to provide. Their solution was to put the professionals in charge and hire others willing to wash bottoms for a smaller wage. They were shocked to discover, right about the time they were expecting to reap the benefits of this new regime, their costs actually started rising!

Unable to comprehend this unexpected outcome, they began to examine what was really happening. Imagine their surprise when they discovered that their patients were staying in hospital longer, for reasons such as serious ulcerations of the areas the bottom-washers were responsible for, new illnesses they had not arrived with, becoming ill with another patients' sickness and falling out of bed. After much deliberation it was determined that having untrained personnel responsible for multiple fragments of the care provided to patients, without any connecting-of-the-dots, was the cause. And so professional nurses were added back into the workplace. Only they were no longer being taught to wash bottoms and needed a lengthy orientation to patient care when they arrived.

It's too bad this isn't a fairy tale. Not in the UK, not in Canada, not in the US... it's real life. Today's nurses are not really being taught to care for patients during their 4 years of university. All of that comes later, once they've been hired into a direct care position where they find they lack the psychometric skills to perform the work. Hence the ever-expanding orientation period.

What used to require a few weeks at most, for the new nurse to become familiar with the ward layout, routines, paperwork and patient population has morphed into an unwieldy period of months. New hires require education not only related to specific patient populations but also a variety of basic nursing skills in order to function independently. The cost of this extended orientation period is exorbitant but must be borne in order to staff our health care facilities.

At the same time, the cost of providing direct care has continued to increase, causing health care systems to look for ways to economise. Because health care is a human-resources dependent endeavour, salaries comprise the lion's share of the budget. So how can a system save money on salaries? Introduce lesser-trained and often unregulated task-oriented personnel who are not responsible for critical decision-making, only to accomplishing their list of tasks... who will be paid considerably less than the nurses formerly providing the care.

Once the thin edge of the wedge has been inserted, the scope of duties these new personnel are performing can be stealthily and deliberately expanded until the nurse becomes little more than a supervisor, but still retains the responsibility and accountability of the profession toward all patients receiving care. Simple, effective implementation of this model of care brings the bottom line down. At least initially.

What leads to the failure of this model is the increase in morbidity and mortality seen once the whole train gets rolling at full speed. Readmissions, health-care related infections, pressure-related injuries, increased lengths of stay, unexpected deaths and other deleterious effects begin to compound on each other and the bottom line eventually suffers. Then the highly-paid and only mildly accountable upper management team rejigs the model, hiring more nurses and utilizing fewer auxiliary staff until the merry-go-round has gone full circle. All of this takes about a decade to complete its orbit, and a new one begins. Over the last two decades this model has been called "staff mix", "team nursing", "alternate models of care", "care delivery model redesign" and "workforce transformation" among others. The name is changed but the model remains the same. And on and on we go. We all know the definition of insanity...

Do we, as nurses, have a professional and ethical duty to combat this deliberate and insidious delegation of our core roles to lesser-skilled, lesser-educated, cheaper personnel? And what do we make the focus of our arguments? Of course we, as nurses, have both professional and ethical duties to our patients and the public at large. We can't make the "protecting our turf" aspect the basis for our debate; this tactic is universally viewed as distasteful and self-serving. However, keeping the patient at the center of our efforts, we are much more likely to capture the attention of the public, who represent our strongest, most effective allies.

The best, most effective method of getting our point across remains education of not only the Powers-That-Be but also the public and each other regarding the depth and breadth of our nursing practice. Over the years I've been told by numerous patients' parents (I have always worked in pediatrics) they had no idea how much nurses do in the day-to-day provision of health care, but their eyes had been opened. They commented on how rarely they spoke to - or even SAW - the most responsible physician, but they were always able to have their concerns addressed and their questions answered by their nurse. They commented on how much responsibility we carry and how our observations and actions have been integral to the patient's recovery.

Until and unless we nurses are able to clearly articulate exactly what we do and how we do it, the merry-go-round will continue its inexorable revolutions. It's very difficult to describe our role in health care and how we actually save lives and money but we have to find a way. Consumers of our services may eventually come to understand that we are not simply angels of mercy, physicians' handmaidens, task-driven routinized cogs in the wheel or bumwipers. We're actually the eyes, ears and hands of the physician, the voice of the patient and the backbone of the system. That's where we start.

Stop the (Deskilling) Merry-Go-Round, I Want to Get OFF!

About NotReady4PrimeTime, RN

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