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

[brianbooth, RN]

Ahhh nursing... while many things have changed over the 10 years that I have been a nurse, one thing that has not is how we treat each other... somehow an article about the deskilling of nursing practise being forced upon us from the outside results in comments undermining one group of nurses by another based on something that the undermined group have no control over. And we wonder why our work environment frequently changes but never gets better.

If, in what I'm about to say, it looks like I've misinterpreted the message of this post, feel free to tell me, and I'll apologise unreservedly.

The majority of responses did not read, to me, like subgroups of one tribe showing resentment towards those of another, perceived to have greater status.

Rather, they show an awareness of some at the beginning of their nursing careers not seeing that there are holes in their learning (how could they?), while some who've been round the block are all too conscious of their own shortcomings.

Whatever piece of nursing qualification paper you hold, to me, you are probably going to be a good nurse if you identify what you're not so good at, and do something to correct the deficit.

I hold it as basic that as you go up the nursing ladder, you should be able, if called upon, to take on the responsibilities and duties of everyone 'below' you, and be able to make a decent fist of the ones immediately 'above' you. If, however, you believe that the people you supervise do one thing (best left to them, being a bit menial) and you do another, then I'm not too hopeful that you'll ever be a respected clinical leader

[rnforforty]

The more education we are forced to get the less we actually get to do. Forty years ago I was placing PICC lines routinely in our ICU. Not any more - if a nurse can do it, it can't be charged for. I've sutured, intubated, read EKG's, done aspiration biopsies, etc., with my Diploma RN. Now, all education gets us is pulled further away from the bedside. Well, I've always noticed that those nurses who 'couldn't' got promotions! Pretty soon, we will all be made redundant!

[Spaceman]

@OP

I understand your position and find that it's commonly held among some nurses, but I have to disagree with your point on the utilization of unlicensed assistive personnel (aka CNA's).

Obviously, in an ideal world, every patient would have his/her primary nurse provide all aspects of care. There is no denying the fact that a nurse might notice a pathology while giving a bath that a CNA might dismiss as normal or insignificant. This knowledge comes with experience. But this doesn't mean that CNAs are simply placeholders and dummies. As a CNA, I routinely notice abnormalities--sometimes critical--and report them to the nurse. Some CNAs who have been on the job for many years pick up a surprising amount of knowledge about pressure ulcer prevention or wound care, and are even more proactive than the nurses about implementing measures that preserve skin integrity and prevent future costs for the hospital. Further, they serve as a second set of eyes. You don't need a nursing license to catch a falling patient or reinforcing fall-prevention education, you just need someone there. And for the salary nurses command these days, that's not going to happen with a RN-only staff

I work on a 30 bed Rehab unit and find a very good partnership between RNs and CNAs. RNs have so many constraints on their time that they just can't give baths and do ADLs on a regular basis. (I am a CNA/nursing student, so I have a foot in both camps) Sometimes a nurse will empty a Foley bag or toilet a pt if I'm behind, and that's great. But it takes a lot of attention to do RN tasks, and tying them up with duties that can be done by someone else. If the CNA lets a patient fall, develop a pressure ulcer, or suffer some other preventable malady, then that NA needs additional training or termination if no improvement. The fact is that CNA's are technically supervised by the RNs, but they are accountable for the care they give.

Edit: As for quality of new grads from some BSN programs, I wholeheartedly agree. I can't tell you how many times a SN asked me which way a bedpan goes, how to perform a stand-pivot transfer, measure respirations, or do some other basic task. I think the preparation of nurses has largely departed from the bread and butter nursing care in favor of esoteric theory. How is that supposed to improve care? Nurses need managers, but we can't all be managers. Most of us have to be caregivers, right?

[PauperRN]

Get a CNA to do NCLEX without attending school and pass. That will really throw a spin into all this conversation. Healthcare is overrated! CNA wants to be a nurse, a nurse want to be a doctor and doctors want to be gods. Everyone should stick to their lanes.

[rnforforty]

I currently teach CNAs and love it. They do the real nursing in most facilities. About forty years ago I learned that they were my eyes and ears. I've experienced the same with LPN's and am upset at the knowledge that so many facilities suffer from the fantasy that they can do without either group and go to an all RN staff. The comment about CNAs taking NCLEX with out proper schooling is ridiculous. But I seen too many nurses pass and STILL couldn't do what a CNA could.

[brianbooth, RN]

PauperRN used a phrase not currently used much, here over the pond: 'everyone should stick to their lanes'. In the UK, 'the cobbler should stick to his last' will probably die out in favour of something like this, as people forget what cobblers are, and may never see a last in their lives.

Yet it ties up so many of the apparent areas of disagreement in the most recent posts.

Firstly, for non-UK readers, the equivalent of a CNA here is a 'health care assistant', or HCA. They may have done some very basic training; they may have gone on and learned many other skills and gained more knowledge, collecting qualifications along the way; or they may fall in the middle somewhere.

Thinking about it, that's not a bad description of an RN... but at its most basic, the knowledge acquired in that training is likely to be at a much higher level.

The HCA who has been in the job for decades is likely to be much more skillful than the newly-qualified RN in the performance of some nursing tasks. How much either person understands the theory behind the performance depends on the individual. You might say: 'the person who can do it best is the best at doing it' - a tautology, surely? But consider the times where things don't go to plan, and you need to improvise. Isn't it conceivable that on those occasions, 'the person who understands it best is the best at doing it'?

I've just thrown these in as thinking points. My personal view is that, whatever a person's rank in the system, their knowledge, experience, and whatever evidence you have as to their abilities to apply them, should be utilised to the full. I know an HCA who can perform an ECG faster than me; so I would always ask her to do it, if time were critical. Yesterday, another HCA solved a problem I'd been wrestling with, on how to give a patient the shower they so much wanted.

But as a thought experiment: think of the best CNAs/HCAs you've ever known, and imagine them as a team running a ward, with no RNs around. Now do the same with all the worst RNs you've worked with, minus HCA support... How similar are the likely ends?

The balanced ward has a mixture of the very experienced, the new boys and girls, and a greater mass in the middle, all progressing towards the top end. Back to the original article: what if you shave off a chunk off each group - the RN component - and replace it with semi-trained individuals? Sure, it'd work for a while, like my imaginary super-HCA/awful-RN run wards would. But there would be a big price to pay at the end.

[phoenoryker]

Here's what I gather... If I want to be a real nurse I should go to the community college and fine tune my butt wiping skills. If I want to be not a real nurse go to a university, so I can later be told by real nurses that I have a degree but I don't no how to properly wipe a butt. Degrees, how silly right? Well, I like silly, so I think I will get the degrees and take the job from the physician that is replaced by mid level work. After all, I like money, probably as much the stakeholders that have created the who shall be the one to wipe a butt. From a patient's perspective, I wonder if there would be a sense of privilege to have my butt wiped by a hand of one who obtained some form of doctorate degree? I think that is what I will do. I am going to aspire to obtain the highest degrees and wipe as many butts as I can on the quest to find out if it was therapeutic to have one's butt wiped by an academic. I will let everyone know the results at a future date. Wish me luck!