Time to call a duck a duck, part II

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eriksoln, BSN, RN

2,636 Posts

Specializes in M/S, Travel Nursing, Pulmonary.
ITA. And why are people treating the OP as if he were the final arbiter on who is/is not a nurse? It's his opinion, nothing more, nothing less.

Because a lot of people are in agreement with...........................we need leadership that doesn't devalue the core of our practice. But, I don't post idea's/threads to say "This is what it is, like it or not" even though my tone might suggest that at times. I'm here to say "This is where I am with things, tell me if I'm right or not." In this thread, at first, a lot of people agreed with me, then the ones who weren't so in love with how I painted the picture came on board. Both sides of it all are of equal value, and everyone who reads through it all has their own place/right to make up their own minds about what is what. I don't see anyone being turned into a "golden calf" or anything.............although, unknown to more than a few posters in here...............I have a few personl/private favorite posters chiming in and making points I do intend to give some serious thought to.

Somebody, Triquee I believe, mentioned how it might be that they internalized this attitude from others while they were at the bedside. I can believe that. It probably describes more of the "nurse administrator who hates nurses" phenomenon that my descriptions do, although I do know the ones I described exist. Still..................food for thought, for both ends.

SharonH, RN

2,144 Posts

Specializes in Med/Surg, Geriatrics.
This is good stuff Sharon and I think it's a bit pointless to be asking whether or not it's nursing. To me anyway, it is. What I wonder is why it is that you 'never laid eyes or hands' on this woman. Surely meeting her, talking to her and maybe her son, and assessing her yourself could only make this process work better? What about visiting her at home to check for falls risk factors like steps, mats, clutter, poor lighting, unsuitable furniture layout, etc? I think this may be what some are meaning when they say 'bedside' or direct care is devalued.

The fact that 'none of her providers have put this picture together' makes me quite uneasy. Why haven't they? They have access to all the same information that you used and they have the advantage of actually talking to her and observing her. It just seems to me that there's something wrong with the entire system when it takes a chart review for someone to notice that this patient has fallen 3 times in the past year, low vitamin D hasn't been followed up, and other potential problems are evident. Surely when she presented with the sprained wrist all this should have been addressed by her provider then? Or am I missing the point and the chart was referred to you because the problems were noted?

I'll take it piece by piece.

As for not laying eyes on her, I totally agree that the idea is to visit the home, meet with her and the son, etc. There is no question of that and certainly no devaluing of the direct care component. It comes down to a matter of resources. I can review 20-30 charts like that a week, but I certainly am not available to see them all. Those who we determine would benefit from a visual are in fact scheduled for an appointment with our team. These are usually patients who have more complex problems that cannot be addressed during a brief phone interview or chart review including memory and cognitive problems.

As for the providers not putting it together, you would be surprised (and disappointed) at how often that happens. There are a lot of factors: they only have 15-20 minutes to see the patient and that doesn't leave a whole lot of time for extensive chart review especially when the patients tend to minimize problems or not tell them at all. They may see different providers who who wouldn't catch on that the patient has been in for the same problem 3 separate times in the last year. And I've found that physicians are not really comfortable assessing psychosocial or functional status unless it is a glaring problem staring them right in the face. That is one area they are perfectly willing to cede to nursing or social work.

This whole thread gives me an idea for a poster presentation. I think it's important for those of us who provide care of patients in the community setting to communicate about the work we actually do and the value of that work to other nurses who may not understand that all nursing occurs at the bedside.

eriksoln, BSN, RN

2,636 Posts

Specializes in M/S, Travel Nursing, Pulmonary.
thanks to you and erik, both. truth be told, my "marginally" skates pretty close to false modesty. an honest self-eval would pretty much just be "competent." i tend to cling to the marginally to remind myself of the point when it finally dawned on me that if i kept trying to be supernurse, i was going to kill somebody, but if i aspired to marginal competence, i might actually get there. and there are still plenty of times when i wonder whether i might have a better future writing about nursing than doing it. i've actually been noodling around the idea of a book, although it has rapidly become clear to me that i need to get some more experience, and possibly do some...eek!... research. and, since i'm being honest, the latter possibility makes the whole idea seem far-fetched. but i really do like the irony that it would be more-or-less a work of nursing theory.

a lot has been posted since i left for work last night, and not all of it delusional. sharon's remark about physical skills reminds me of a post i saw on another thread suggesting that cnas could pick up a lot of what we do over a matter of, i think it was months. but i didn't read her to mean bedside nursing was only about physical skills. i'm also reminded of a story my dad told me of seeing a child prodigy interviewed on t.v. when asked how his parents related to him, he said he thought that his father might be a little uncomfortable, since he "worked with his hads." what did his father do? he's a neurosurgeon. which in turn reminds me of all the times in my own childhood that my father asked me why they don't send donkeys to school. (because nobody likes a smart ass.)

i'm going to have to wait until my gcs is in double digits to develop this thought, but while i do genuinely think bedside nursing is the core of nursing, my personal inclination is to consider just about any job with "nurse," in its title a nursing job.

yep. that was me...............................:o. not very long ago either. from "duck i" to "hospitals only hiring bsn" and then back to this, "duck ii". big change huh? if anything, its documentation to the fact that i do internalize what i learn on here quite a bit, even if my demeanor suggests otherwise.

you know, when i started this thread, i expected it to take a different direction. i, at some point, thought "what theorist best suits this line of thinking?" would come up. i really wanted to discuss, on a lot of lvls, how gene watson is my new found/loved "theorist". i've seen her bashed a lot on this site, but i think they missed her point.

http://www.innovativecaremodels.com/uploads/file/caring%20model/overview%20jw%20theory.pdf

pretty much self explanatory why i've, in the past few weeks, come to realize this is the "theory" or face of nursing that works best for me. i almost take her insertions that "caring" is an endorsement of professional nurses identity as a sort of war cry or rally cry to protect the one thing nurses do that separates us from the business minded folk.................pt. contact. we truly are the mediators for our patients these days, and the enemy has changed. we no longer are just fighting disease............and, in fact, our greatest enemy is often.........the very institution we choose to deliver nursing care in. idk, i just might be rambling again, and i get in trouble when i do that:p.

eriksoln, BSN, RN

2,636 Posts

Specializes in M/S, Travel Nursing, Pulmonary.
I'll take it piece by piece.

As for not laying eyes on her, I totally agree that the idea is to visit the home, meet with her and the son, etc. There is no question of that and certainly no devaluing of the direct care component. It comes down to a matter of resources. I can review 20-30 charts like that a week, but I certainly am not available to see them all. Those who we determine would benefit from a visual are in fact scheduled for an appointment with our team. These are usually patients who have more complex problems that cannot be addressed during a brief phone interview or chart review including memory and cognitive problems.

As for the providers not putting it together, you would be surprised (and disappointed) at how often that happens. There are a lot of factors: they only have 15-20 minutes to see the patient and that doesn't leave a whole lot of time for extensive chart review especially when the patients tend to minimize problems or not tell them at all. They may see different providers who who wouldn't catch on that the patient has been in for the same problem 3 separate times in the last year. And I've found that physicians are not really comfortable assessing psychosocial or functional status unless it is a glaring problem staring them right in the face. That is one area they are perfectly willing to cede to nursing or social work.

This whole thread gives me an idea for a poster presentation. I think it's important for those of us who provide care of patients in the community setting to communicate about the work we actually do and the value of that work to other nurses who may not understand that all nursing occurs at the bedside.

Do you mean "not all" nursing...........................................

So, what is the name of your committee? What is a group that performs your role likely to be called at other hospitals?

eriksoln, BSN, RN

2,636 Posts

Specializes in M/S, Travel Nursing, Pulmonary.

IBTL

Maybe I should learn to spell Jean Watson before I claim her as my guiding theorist:o

llg, PhD, RN

13,469 Posts

Specializes in Nursing Professional Development.
This whole thread gives me an idea for a poster presentation. I think it's important for those of us who provide care of patients in the community setting to communicate about the work we actually do and the value of that work to other nurses who may not understand that all nursing occurs at the bedside.

I wrote a paper on a similar topic in graduate school. It focused on the fact that many people feel that anyone who is not a bedside staff nurse is not a "real nurse." I traced the history of the definition of nursing from Nightingale, through Henderson (both of whom had broad conceptualizations of the profession that included all types of nursing practice, not just bedside) ... to then contemporary views of the profession that include multiple nursing functions and roles.

I lamented the fact that while most scholars have a broad view of nursing, a narrow and limited view (the "bedside only" view) is often found in everyday life. It is a nursing cultural norm to condone -- or at least tolerate -- the bashing of any nurse who advances or expands her scope of practice. It's a almost institutionalized form of bullying that hinders both the professional development of individuals and the profession as a whole by making it socially undesirable for young nurses to want to further develop their skills to include a wider range of skills and knowledge in realms of nursing practice beyond the bedside.

Good luck with your poster idea!

nursemike, ASN, RN

1 Article; 2,362 Posts

Specializes in Rodeo Nursing (Neuro).
IBTL

Maybe I should learn to spell Jean Watson before I claim her as my guiding theorist:o

I thought maybe in a dramatic show of support for men in nursing, she got a sex change. Which would be dramatic.

I was talking to a friend, an aide, who was contemplating nursing school, but worried as a nurse she might not get as much hands-on time with pts. Being a 1st year ASN student, I wisely assured her that the nurses she saw who spent most of the time charting were the ones who wanted to spend most of their time charting. Well, I was young. Okay, 46, but young at heart. Or young to nursing, anyway.

Now, everyone bearing in mind that I can't seem to find my flame-proof boxers, the train of thought that there are parts of nursing even a monkey could do got me thinking about our aides. And what occurred to me is that pretty much everything an aide does is a nursing function. Which, sadly, doesn't seem so true of what nurses do. I'd call my friend and apologize, but she's far enough in school, now, that it would be a shame to quit, and she could use the RN pay. And I wasn't totally full of it. Given the limited time in a nursing shift, we all--don't we?--have to decide which of our expectations we are going to neglect. A lot of my favorite nurses, including me, are pretty deplorable charters.

Another friend, who is a thorough documentarian, inspired me to decide that all parts of the nursing process are important, but without intervention, all of the other parts are just words. To me, the point of assessment and diagnosis is figuring out what needs done first. Evaluation is figuring out whether it worked. Planning is going back later and thinking of an excuse for what I did. (My nursing remains a work in progress, and probably always will.) But I think I agree that bedside nursing is the core of nursing because I think doing stuff is the core of nursing. And that belief is how I can incorporate nurses who practice away from the bedside as actual nurses. Sharon's description of her practice doesn't sound like my cup of tea, but she does perform interventions. My nurse manager performs interventions, as best as her progressive dementia permits.

Awhile back, I posted on my facebook status that I didn't become a nurse to write thorough histories of a patient's decline. I stand by that. But a week--maybe a month?--later, I was pushing benadryl for dyspnea. None of us is perfect, and some of us aren't even close. (I still don't think I was totally nuts--ya had to be there--but in retrospect, I'd probably wait until the next time he was extubated to address his psychosocial issues.)

Eh, my GCS is slipping again. Gotta get ready for work. But I want to mention having read about an ANA position paper that, as I understood it, claimed LPNs aren't real nurses, and that all real nurses should be BSNs. So I, an ASN, shouldn't be a nurse. Which, despite recently cited evidence (see above) isn't true. Practical nursing, be it licensed or registered, is real nursing. Practical nursing is the I in ADPIE. But, no, it isn't the whole of nursing. Not every intervention (ahem) is a good one. The nurse who writes during a code is doing a necessary job that the ones doing compressions didn't want to do, anyway. So I'll back off my previous view that the nurses who run the ANA aren't real nurses. Actually, I don't think I've ever met any. I still believe there are nurses in non-bedside roles because they just couldn't wait to get away from bedside nursing and don't think much of bedside nurses, but my knees are already wondering how much longer I can do this and how my butt could serve my patients.

eriksoln, BSN, RN

2,636 Posts

Specializes in M/S, Travel Nursing, Pulmonary.
I wrote a paper on a similar topic in graduate school. It focused on the fact that many people feel that anyone who is not a bedside staff nurse is not a "real nurse." I traced the history of the definition of nursing from Nightingale, through Henderson (both of whom had broad conceptualizations of the profession that included all types of nursing practice, not just bedside) ... to then contemporary views of the profession that include multiple nursing functions and roles.

I lamented the fact that while most scholars have a broad view of nursing, a narrow and limited view (the "bedside only" view) is often found in everyday life. It is a nursing cultural norm to condone -- or at least tolerate -- the bashing of any nurse who advances or expands her scope of practice. It's a almost institutionalized form of bullying that hinders both the professional development of individuals and the profession as a whole by making it socially undesirable for young nurses to want to further develop their skills to include a wider range of skills and knowledge in realms of nursing practice beyond the bedside.

Good luck with your poster idea!

Ah, but we are talking about different things now.

My goal: Bash (yes, bash, to death if need be) the attitude that bedside nursing is "remedial" or work meant for "the techs who can't grasp the whole scope of things thus are better meant for the physical labor." The Core of nursing is at the bedside, you don't deliver theraputic touch or communication from behind desk or through emails. With that in mind, any view/theory of nursing that devalues bedside nursing is pointless.

My goal is not to: Bash anyone who doesn't have direct contact with patients. If your role, as an administrative nurse, is to foster better pt. care via good management/decision making.............then by all means, get your jiggy with it and continue. Only a few good/well informed (that's where the nursing background comes in) decisions that mold/shape a facility are necessary to foster enormous change in bedside nursing and the facility as a whole. Who could find a problem with this?

But is that what is going on? Not in my experience. What I see happening is: Decision makers hand pick nurses who are more apt to be absorbed into their culture/way of thinking for administrative roles. These nurses then become the "Wolf in Sheep's Clothing" I identified earlier..................and all of a sudden you have a nurse who not too long ago was struggling at the bedside making comments like "Bedside nursing is remedial".................."Bedside nursing is just physical labor, anyone can do it".....................or "Bedside nurse's views should be taken into account, with a grain of salt since their understanding of the whole picture is slanted/limited."

Then, you have some CEO make outlandish suggestions, and said nurse who is in a position to guide/direct them fumbles the ball. A good example would be the LTC whose decision makers decided turning off the hot water each weekend would save the facility money. Now, IDK about you, but I don't think it takes a degree to see the problems there. As a former nurse, one who sits on the board and helps make these decisions, one would think the one with a nursing background would have quipped up and explained "Ummmm, that's a terrible decision. Nursing care doesn't stop just because its Sat. or Sunday. Furthermore, elderly people are more prone to be cold already because......................" But no, no such thing happened. The leaders of the LTC facility kept their mouths shut and let it go on, expecting prepared scripts of what to say about it to solve any complaints. Now, my guess is, this facility had a lot of leadership who were the sort to make comments like what I described above.

Maybe I'm just expecting too much of our leaders when I look at things that way, IDK. I know as a bedside nurse, the gap between expectations and reality are wider than the ocean. Maybe I'm doing to our leaders what often is done to me, I'm handed the fixings for a burger and told to make a steak/lobster dinner of it. Perhaps they don't have the pull/say in things I think and are just scrambling to get the day done, much like me.

If thats the case, then yes, I'm being too harsh. I'm not of the opinion that is the case though. Its hard to side with/stand by someone when you know................more than likely, their true colors are that you are "remedial" and don't matter.

I couldn't help but notice, your "poster" concerning nurses bashing nurses was one sided. Talked about bedside nurses who don't think any "real" practice goes on anywhere except the bedside. Somehow, the leaders who commit the same crime with regards to bedside nursing were left out. Coincidence? I don't think so.

Yes, many bedside nurses believe the world begins and end with their perspective on things. But, even more damaging is an administrative nurse who believes the same. The bedside nurse who speaks their voice is VERY unlikely to be heard. On the other hand, an administrator is going to be heard, and many decision makers base their opinions of nursing on what they say/show. One slip from a nurse in an administrative role can cause a lot of grief for the floor nurses. Hence, my insertion that we either, as nurses remember our roots or........bedside nurses separate. I'll risk nursing being more limited in its scope to be free of leaders, leaders who come from our own ranks especially, who believe the very core of what we do is of no value.

Specializes in ICU.
If it is not charted, you didn't do it.

Careplans in the mind is all well and good...for the people who can read minds.

Huh??

Here's left field [[[[you]]]] -----------------------------------------> Here's what I'm talking about.

eriksoln, BSN, RN

2,636 Posts

Specializes in M/S, Travel Nursing, Pulmonary.
Huh??

Here's left field [[[[you]]]] -----------------------------------------> Here's what I'm talking about.

It took me awhile to get that. :p

"It's triquee to rock around, to rock around that's right on time, it's triquee"

Specializes in ICU.
"It's triquee to rock [rhyme], to rock [rhyme] that's right on time, it's triquee"

It is...It is, indeed.

CompleteUnknown

352 Posts

I'll take it piece by piece.

As for not laying eyes on her, I totally agree that the idea is to visit the home, meet with her and the son, etc. There is no question of that and certainly no devaluing of the direct care component. It comes down to a matter of resources. I can review 20-30 charts like that a week, but I certainly am not available to see them all. Those who we determine would benefit from a visual are in fact scheduled for an appointment with our team. These are usually patients who have more complex problems that cannot be addressed during a brief phone interview or chart review including memory and cognitive problems.

As for the providers not putting it together, you would be surprised (and disappointed) at how often that happens. There are a lot of factors: they only have 15-20 minutes to see the patient and that doesn't leave a whole lot of time for extensive chart review especially when the patients tend to minimize problems or not tell them at all. They may see different providers who who wouldn't catch on that the patient has been in for the same problem 3 separate times in the last year. And I've found that physicians are not really comfortable assessing psychosocial or functional status unless it is a glaring problem staring them right in the face. That is one area they are perfectly willing to cede to nursing or social work.

This whole thread gives me an idea for a poster presentation. I think it's important for those of us who provide care of patients in the community setting to communicate about the work we actually do and the value of that work to other nurses who may not understand that all nursing occurs at the bedside.

Disappointed yes, surprised not really.

Sharon and llg, I agree with most of what you say, but I do think erik is on to something as well, I'm still having trouble articulating it. I have a foot in each camp, I do a bit of both (bedside some days and administration/case management type stuff other days). I think nursing as a whole is too willing to give away the 'basic care' part of our job to unlicenced staff. That does indicate to me that what we know as basic nursing care is perhaps not really valued by our nursing leaders. There's a lot about advancing our scope but not so much about how we make sure we retain the essence of what we are. When I'm wearing my management hat I miss the satisfaction of direct care, when I'm at the bedside I miss the ability to at least try to make changes for the better. I want my scope expanded, not just advanced!

No doubt I'll be howled down for saying this next bit but I'd almost rather see us give away medication administration before we give away basic care. It's the understanding of what is likely to happen once that medication is given and the monitoring of the body's response that requires special knowledge and understanding, not so much the actual physical administration of the medication. There are IV teams, why not medication teams? They could go from unit to unit in an orderly fashion and thus ensure that medications are given within the approved time frames. (kidding, mostly!)

When medical care has failed, or done all it can, when there are no more medications or surgeries or procedures or other treatments, all that is left is nursing care. Isn't that important enough for us to never give away? Or maybe I am just hopelessly out of date and basic nursing care isn't what we're about any more.

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