The 'De-Skilling' Of Nursing

[TheCommuter]

What should be our greatest concern for the future of nursing?

We must fear the day if (or when) registered nurses (RNs) and licensed practical nurses (LPNs) will be less needed in healthcare due to systematic de-skilling of the nursing profession. Even though patients are becoming sicker and more complex in today's healthcare system, other professionals and paraprofessionals have started to perform tasks and assume roles that had once been within the strict realm of licensed nursing personnel.

The de-skilling of the nursing profession has been taking place for quite some time. For example, we have phlebotomists and phlebotomy technicians to draw blood in certain healthcare settings.

Medication aides regularly administer medications in many nursing homes, group homes, and assisted living facilities, even though the task of medication administration had once been a duty that was strictly performed by licensed nursing staff.

Some hospitals have policies that allow patient care assistants to insert and remove indwelling urinary catheters and discontinue peripheral IV catheters.

Some rehabilitation facilities and specialty hospitals have assembled wound care teams that consist of physical therapists and occupational therapists who perform all the dressing changes and handle all the complex wound care cases.

Many back office medical assistants now perform advanced skills in doctors' offices under the supervision of the physicians who employ them.

Pharmacy technicians now mix medications in hospitals on a regular basis, but RNs were once able to mix drugs in piggybacks for IV administration.

Rehab techs now ambulate patients post operatively when licensed nursing staff used to be the ones to ambulate 'early and often.'

More examples of de-skilling in the nursing profession exist. For instance, many healthcare facilities employ lay people to do the staffing and scheduling for nursing staff. These schedulers are given the fancy titles of 'staffing coordinator' or 'director of staffing,' and have been given responsibility for an administrative aspect that nursing management or supervisory staff strictly performed once upon a time. In addition, some emergency departments are considering hiring paramedics to lessen the need for ER nurses.

The writing is on the wall.

The nursing profession must stop surrendering our valuable skills to other healthcare workers now. Nurses need to fully embrace their skill sets and constantly be on the lookout for other disciplines who are attempting to remove yet another skill away from our roles. If even one unemployed nurse exists who needs a job, then de-skilling is a problem because non-nursing staff are displacing licensed nurses. If this systematic de-skilling does not stop anytime soon, the future of nursing might be in trouble.

[nursel56]

Can you please site some of these studies? I've done a quick search myself and the primary studies I have found are more related to staffing ratios and nursing care environments than the education of the nurses on the units. The only study I found that considered education level of nursing staff was from JONA:

"Results: Controlling for patient acuity, hours of nursing care, and staff mix, units with more experienced nurses had lower medication errors and lower patient fall rates. These adverse occurrence rates on units with more baccalaureate-prepared nurses were not significantly better."

Source: Nurse Experience and Education: Effect on Quality of Care : Journal of Nursing Administration

That's an interesting result because one of the findings of the so-called "landmark" study by Linda Aiken in 2003 used a model that included the finding that experience is of little importance. Instead of questioning the model they reported in their conclusions that we might be over-emphasizing the importance of experience.

[TheCommuter, BSN, RN]

Perhaps facilities and units staffed with a greater proportion of BSN-educated nurses result in better outcomes because RNs with BSN degrees are typically less likely to end up in settings with horrid nurse/patient ratios (LTC, acute rehab, prisons) and more likely to work in settings with lower nurse/patient ratios (acute care hospitals).

[VICEDRN, BSN, RN]

There is no endless or ever growing pile of studies on BSN nurses and patient mortality. There has been only one study by Linda Aiken so it's far from being a basic fact of life. It's another example where if something gets repeated enough times, it starts to become accepted as the truth.

No. There are at least three studies and I know of at least one study that is a meta analysis of other studies.

From: American Association of Colleges of Nursing | Creating a More Highly Qualified Nursing Workforce

• In the January 2007 Journal of Advanced Nursing, a study of 46,993 patients conducted by researchers at the University Toronto found that hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. The findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients.
  
• In a study published in the March/April 2005 Nursing Research, Dr. Carole Estabrooks and her colleagues at the University of Alberta found that baccalaureate prepared nurses have a positive impact on mortality rates following an examination of more than 18,000 patient outcomes at 49 Canadian hospitals. This study, The Impact of Hospital Nursing Characteristics on 30-Day Mortality, confirmed the findings from Dr. Aiken’s landmark study from 2003.
  
• In a study published in the September 24, 2003 Journal of the American Medical Association, Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level. A 10% increase in the proportion of nurses holding BSN degrees decreased the risk of patient death and failure to rescue by 5%.
  

For more information on the link between nursing education and patient outcomes, see www.aacn.nche.edu/media-relations/fact-sheets/impact-of-education.

[VICEDRN, BSN, RN]

Perhaps facilities and units staffed with a greater proportion of BSN-educated nurses result in better outcomes because RNs with BSN degrees are typically less likely to end up in settings with horrid nurse/patient ratios (LTC, acute rehab, prisons) and more likely to work in settings with lower nurse/patient ratios (acute care hospitals).

I don't think so because the studies compared units in acute care facilities, not nurses at different types of hospitals.

[nursel56]

Perhaps one could get their sources from an unbiased observer?

[VICEDRN, BSN, RN]

Perhaps one could get their sources from an unbiased observer?

Nursing journals, JAMA and IOM have all reviewed the issue. There are tens of thousands of patients in at least two countries. At this point, it's about believing what you want to believe, not about questioning the work itself.

[nursel56]

Nursing journals, JAMA and IOM have all reviewed the issue. There are tens of thousands of patients in at least two countries. At this point, it's about believing what you want to believe, not about questioning the work itself.

Not really. The IOM is joined at the hip with the AACN, and JAMA doesn't vouch for everything it publishes. Here is an excerpt of what a panel of researchers hired by the AACC found as the major flaws in the study.

Associate Degree Nurses Vital to the Nation's Health Flawed Study Unduly Alarms Public

[VICEDRN, BSN, RN]

Not really. The IOM is joined at the hip with the AACN, and JAMA doesn't vouch for everything it publishes. Here is an excerpt of what a panel of researchers hired by the AACC found as the major flaws in the study.

1. Dismissing the study’s own major finding:

2. Simple logical fallacy:

3. Experience matters: T

4. Self-Selected Respondents Skew Data:

5. Loading the Deck:

7. True Representation?:

Really. You are responding to the one study that was completed in PA. There are more studies, including the one done in Canada. I think we can imagine that in Canada, resources are divided a little more evenly since they have a universal coverage system.

You also neglect the fact that the sheer volume of participants in these studies actually decreases the likelihood that the outcome is not correlated with the findings. Also, since I work at a large institution, the logic that more patients die at smaller institutions makes no sense to me. Smaller institutions do not take the high acuity trauma patients and medical patients that we do and if they do, they ship them to us so they can die in our ICU. They simply aren't equipped to do anything but intubate these folks and ship them to the big city.

The only thing we agree on is that the studies are a smoking gun and do not provide us with a reason why the baccalaureate prepared nurses tended to have better outcomes as a group.

[nursel56]

The only thing we agree on is that the studies are a smoking gun and do not provide us with a reason why the baccalaureate prepared nurses tended to have better outcomes as a group.

No argument there! The PA study is the study that is consistently pointed out as "proof" you are more likely to die if an ADN nurse takes care of you after your surgery. Thanks for turning that tome into a short list, though! :)

[VICEDRN, BSN, RN]

No argument there! The PA study is the study that is consistently pointed out as "proof" you are more likely to die if an ADN nurse takes care of you after your surgery. Thanks for turning that tome into a short list, though! :)

I think the logical leap is that you are more likely to die if your nurse is an adn but this, in fact, has not been studied and no matter where I am, I won't claim that as the findings.

[tnmarie]

I admit that I haven't read any of these studies (yet!) but there are so many variables in patient care settings (and in nurses, regardless of their education) that I don't see how they can make the claim that the BSN has such an influence on pt outcomes. I don't see how the kind of controlled study that it would take to make such a claim would be remotely possible. I may be "just" an LPN but even I know that correlation =/= causation. I'm really interested in seeing the studies though. Thanks for posting info on them! And thanks for the interesting debate about them.

I also agree with the previous poster about bias. The BSN prepared RN's study finds that units with more BSN prepared nurses have lower mortality rates, hmmm. You can't discount a study just for that but it should at least give you pause and cause you to do more research before rushing out to get your BSN or causing you to dismiss your ASN nurse the next time you find yourself in a hospital.

[wooh, BSN, RN]

Why do we even bother going to nursing school at all? All that counts is experience. Education is useless. Let's just license high school graduates. Heck, why bother with that? If you're old enough to work after 10pm, come on in.