de-skill [dee-skil] verb (used with object) to remove any need of skill, judgment, or initiative in: jobs being deskilled by automation. Health care experiments in deskilling the work force seem to crop up about once a decade. How does it happen and what can we do?
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.
And IMO (I probably will be flamed for this) but the NCLEX has been simplified over the years. I remember the 2 days from hell and hundreds of questions (400?). Now a new grad can pass at 75. If healthcare has gotten increasingly complex, how can a new grad only be tested with 75 questions?I know..minimal entry as an RN, but still, IMO it's not enough.
I agree, I think nursing school focused more on passing the NCLEX, so schools look good.
Because your ability to practice should not be examined for in the NCLEX that is decided by you passing your accredited program. Your ability to practice safely is what should be examined in the NCLEX.
Because your ability to practice should not be examined for in the NCLEX that is decided by you passing your accredited program. Your ability to practice safely is what should be examined in the NCLEX.
How can you judge the ability to practice safely with only 75 questions??
Heck, my certification test for med/surg was a 150 questions, and I had to answer every single one. No computer shut off at 75!
This student also made it clear that she had no intention of learning bedside skills. She stated she was going to go into management so she didn't need to learn how to care for a patient. Ultimately she was failed from the program 2 months from graduation. The school was very surprised to discover she couldn't perform basic skills.
Unfortunately this attitude is not uncommon.
And IMO (I probably will be flamed for this) but the NCLEX has been simplified over the years. I remember the 2 days from hell and hundreds of questions (400?). Now a new grad can pass at 75. If healthcare has gotten increasingly complex, how can a new grad only be tested with 75 questions?I know..minimal entry as an RN, but still, IMO it's not enough.
I agree, I think nursing school focused more on passing the NCLEX, so schools look good.
It's a Computer Adaptive Test. The computer adjusts the level of difficulty of the questions to match your knowledge level. Harder questions are worth more points.
There are any number of facilities who will do just about anything to retain a fully BSN staff.BSN prepared nurses may have some clinical experience, but for any number of them it is a means to the end of either managment or specialties. I am not sure where the programs are that allow students in the US to actually start IV's, etc. But if they are there, it should be the go to school.
Unfortunetely, they keep ADN's, Diploma RN's and LPN's around just long enough to teach a new nurse the very basics of bedside care, then they are on their own, as then everyone else is phased out. And quite honestly, a nurse can "get around" basic care--and it happens every day--there is more than one school that has a whole class on "delegation" and well, if there's no one to delegate to--ah, well, they are going home tomorrow anyways.
Local community or state schools should not be discounted. Many have excellent programs. As noted by their long waiting lists. This adds to the elitist nature of private expensive schools. They all teach the same thing, however, the "label" makes it better? I am not so sure that is the case.
I am entering my senior year of a BSN nursing school (state university), and I have only placed in one foley and one IV (but I work as a tech and routinely do blood draws, and my old job allowed techs to foley/straight cath), but I have worked with several vented patients, have learned about tube feeds, have given numerous IM/SQ injections (including working with insulin) and IV push meds along with hanging numerous bags, setting up the IV pumps, and have performed wound care. I haven't placed in NG tubes or perform trach care, unfortunately.
Not everyone gets an opportunity to put in a foley or IV or work with a vented patient. Some hospitals severely limit what nursing students can do, no matter the degree, for liability reasons. Back in the day, nursing students could do MUCH more with patients and weren't put on a tight leash. I would love to have gotten more hands on experience, but we are limited to the amount of care we are allowed to provide.
To the OP,
You do make excellent points that I agree with. However, nursing instructors have all told me that the thing that separates the nurse from all others is her/his assessment skills. My teachers have even gone as far as to say that they could teach a monkey how these skills, but they cannot train them to think critically or assess a patient, the hallmarks of nursing. That isn't to say that the psychomotor skills aren't important because they are, however, what is the point in knowing how to perform tasks but not knowing why?
I worked with a nurse who refers to baths and toileting as CNA work. Totally blew me away. You can find out so much about your patient if you actually touch them beyond a simple assessment of breath and bowel sounds.
I work as an aide and have heard this far too many times. There is no such thing as "CNA work" as "CNA work" is really just basic nursing care.
It's a Computer Adaptive Test. The computer adjusts the level of difficulty of the questions to match your knowledge level. Harder questions are worth more points.
Yeah, but why the change? We did hundreds..hundreds of questions and it was rare to have an easy question. You HAD to study to pass the old NCLEX. I still don't buy that you can assess competency in 75 questions. As I said before, even my certification was a 150 with no shut off.
IMO the newer NCLEX dumbs down nursing. Does an MD have a computer shut off at 75?
I often wonder when new grads are stating they have few skills when leaving nursing school what kind of a rinky-dink college they went to. I understand college is different now, but nursing is actually more skilled than ever. I am leery of the computer testing. It is scary that there is only 75 questions between a ditch digger and an RN.
You do make excellent points that I agree with. However, nursing instructors have all told me that the thing that separates the nurse from all others is her/his assessment skills. My teachers have even gone as far as to say that they could teach a monkey how these skills, but they cannot train them to think critically or assess a patient, the hallmarks of nursing. That isn't to say that the psychomotor skills aren't important because they are, however, what is the point in knowing how to perform tasks but not knowing why?
My question is: how do we assess our patients if we're not even touching them? If an aide is doing the bottom washing, tube feed hanging, med passing and ambulating am I - the RN responsible for assessing the patient - going to know that Mrs Smith in 321B is unable to turn herself at all, or that Mr Jones in 325A has new onset difficulty swallowing his meds, or that the young person with cancer in 318 has a skin tear between her buttocks? When I'm the one doing the bottom washing, I'm assessing the patient's skin integrity and motor strength, making note of quantity, colour and consistency of stool, and even assessing mental status by engaging the patient in conversation. The aide knows how to wash bottoms. Or hand over a med cup with a handful of tablets in it. Or how to set a rate on a feeding pump. Their focus is the task. For the RN or LPN, the focus is the patient; the task itself is secondary.
My question is: how do we assess our patients if we're not even touching them? If an aide is doing the bottom washing, tube feed hanging, med passing and ambulating am I - the RN responsible for assessing the patient - going to know that Mrs Smith in 321B is unable to turn herself at all, or that Mr Jones in 325A has new onset difficulty swallowing his meds, or that the young person with cancer in 318 has a skin tear between her buttocks? When I'm the one doing the bottom washing, I'm assessing the patient's skin integrity and motor strength, making note of quantity, colour and consistency of stool, and even assessing mental status by engaging the patient in conversation. The aide knows how to wash bottoms. Or hand over a med cup with a handful of tablets in it. Or how to set a rate on a feeding pump. Their focus is the task. For the RN or LPN, the focus is the patient; the task itself is secondary.
Exactly. students that really don't care will use the old " a monkey could do the tasks" line. They don't get it.
Rose_Queen, BSN, MSN, RN
6 Articles; 12,057 Posts
Not flaming; I'm one of those 75 question passers and I thought it was far too simple. I'd rather see not only a test but also competencies required.