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Time to call a duck a duck, part II

Nurses   (17,530 Views 158 Comments)
by eriksoln eriksoln, BSN, RN (Member)

eriksoln has 15 years experience as a BSN, RN and specializes in M/S, Travel Nursing, Pulmonary.

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You are reading page 3 of Time to call a duck a duck, part II. If you want to start from the beginning Go to First Page.

heron has 40 years experience as a ASN, RN and specializes in Hospice.

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Totally agree with you heron. The thing that worries me though is that I really do feel there are nurses who just cannot see that famous 'big picture' (maybe it's an experience thing and that makes it difficult when the brand new nurse is expected to be able to perform at the same level as the experienced nurse) and I wonder how much of that has contributed to the introduction of case management.

You have a point ... but I don't personally think that concerns over experience had much to do with the change. If memory serves, it came about as the for-profits started taking over the industry in the late eighties to early nineties. That's when staffing got cut and CNA's were largely eliminated on many acute care units.

Case management got big when they realized that they threw the baby out with the bathwater. Having bedside nurses doing the job, however, was costly ... more nurses, more overtime or both ... and behold - a new job description for a nurse who could case manage an entire unit on salary, because it was not direct care.

Edited by heron
better wording

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All upper management care about is profit that's why you have the patient workload that you have and to the person that said I have to remind the nurse how they should be charting if I didn't have so many patients and so many responsibilities then maybe I could be thorugh as you like but if I have a pt over load usually one line charting will be it for me and no upper management does not need to get those high bonuses that they receive they can just easily as well invest in more nurses on the floor at some point they say we don't have money for this or that more staff but somehow they manage to get bonuses every quarter at the patients peril and your license ? There is no way one nurse can take care of 30 patients inltc they wouldn't dare try in a hospitsl setting so why in ltc or 50to 60 at night how can you possible give good quality care plus your other responsibilities but they cut staff then turn around and give manager soinso a bonus big you can by a lamborghini with plus a mansion maid and butler to match

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eriksoln has 15 years experience as a BSN, RN and specializes in M/S, Travel Nursing, Pulmonary.

2 Articles; 19,508 Visitors; 2,636 Posts

i'm happy to read that you now consider nursing to be a profession ... and i agree that some of our leaders have forgotten their roots. i also would never hire anyone for a leadership position who had not actually provided direct patient care. so, i agree with much of what you wrote in this thread.

but i am disppointed to find that you think that only 1 type of activity counts as actual nursing. there are many different roles for nurses, not just the one that appeals to you the most.

... and we are all real nurses. we just don't all do the same job. we "take care" of the patients in different ways. we are all valuable. don't bash other nurses because they focus on on other aspects of nursing. that is one of our professions biggest problems -- we don't support each other and recognize the legitimacy of other people's perspectives. we put down those who disagree with us and/or focus on a different aspect of nursing. please don't divide our profession and tear it apart. we need to stand together -- and we can't do that if can't recognize that nurses in roles different from our own are also real nurses.

edit: i just read your post about "real nurses" in the other thread ... the one about nurses insulting other nurses because of their specialty. while you are not exactly inconsistent in these two threads ... i don't think you have fully thought it through and still need to think about how the two topics relate.

ok, i'll answer here instead of putting answers all over the place..................cause we need to conserve paper................errrrr, wait. ok, i'm just lazy.

i don't see the connection between this thread and that one. you'll have to elaborate on that one for me. i'm not being smart, i like you and wouldn't do that to you, this is me being honest. i don't get it. it's over my head.

this thread: nursing is a profession, and we need to make some changes with/in our leadership so others see it.

that thread: dept. 2 dept. infighting.

idk. maybe i do get you. there was a point where i considered putting in some disclaimers regarding how i've seen a great many non-bedside nurses act. is it my stance that if we remove bedside care from the nursing spectrum, that its no longer nursing that you don't like? this stance should not be interpreted as "unless you are at the bedside at least x times/week and answer y call bells/day, you can't contribute to nursing, so don't call yourself a nurse." i feel my explanation given to the other poster makes that point.

my "nursing is not the same if we take away the bedside care" stance should be taken as.........a sort of personal missions statement and a call to arms for fellow nurses. it is my answer to the many (not some, as your experience seems to be) nurses who, once in a position of leadership, away from the beside, for some reason decide being at the bedside means being left behind. i don't get that. the point of the medical field as a whole, and of nursing, is to generate good outcomes for the patient. that can not be done without the bedside nursing................period, no room for interpretation or debate there. and, since bedside nursing is a vital part of pt. outcomes...............what is gained by allowing our nursing leadership positions to be filled by those who so often scoff at the idea of it and devalue it?

maybe its my "qb doing public speaking" comparison that throws things off. idk, you tell me, is it? is saying the nurse who does not practice at the bedside is not actively nursing too far a stretch? i'm comfortable with it. i'm not saying they are not a nurse anymore or any less of a nurse, just that office work and paperwork are not "nursing". that has more to do with my attitude towards the paperwork that seems to dominate our day than with who can call themselves a nurse. guess what? when i am sitting at the nurse's desk, angry as heck cause i want this/that form done so i can go do "nursing", i don't feel like much of a nurse. thats where that comes from.

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eriksoln has 15 years experience as a BSN, RN and specializes in M/S, Travel Nursing, Pulmonary.

2 Articles; 19,508 Visitors; 2,636 Posts

My point is "Its all nursing".

I got that.

My point was, it's not all nursing..................it's a nurse contributing to the team from a different role.

I'm not devaluing your contribution or saying anything like "Your not a real nurse".......................just saying, you are, while doing the job you described, performing a position that would better be described as administrative. Is that a bad thing?

Outside dept's and other positions do contribute to the nursing field, and you, with a background of nursing, are in such a position. Why is that bad? I have to missing something.

Saying you are "nursing" while never going anywhere near a pt. is like...................well, take my QB doing public speaking example: Being on the field, throwing the FB is what makes him a football player. Now, lets say for w/e reason, he decided public speaking was more to his liking. He hasn't thrown a FB in years now, never goes anywhere near the field...............is he still playing football? He's still giving public speeches, and other QB's do that................so he is playing FB, right? No.

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heron has 40 years experience as a ASN, RN and specializes in Hospice.

1 Follower; 37,938 Visitors; 2,494 Posts

I got that.

My point was, it's not all nursing..................it's a nurse contributing to the team from a different role.

I'm not devaluing your contribution or saying anything like "Your not a real nurse".......................just saying, you are, while doing the job you described, performing a position that would better be described as administrative. Is that a bad thing?

Outside dept's and other positions do contribute to the nursing field, and you, with a background of nursing, are in such a position. Why is that bad? I have to missing something.

Saying you are "nursing" while never going anywhere near a pt. is like...................well, take my QB doing public speaking example: Being on the field, throwing the FB is what makes him a football player. Now, lets say for w/e reason, he decided public speaking was more to his liking. He hasn't thrown a FB in years now, never goes anywhere near the field...............is he still playing football? He's still giving public speeches, and other QB's do that................so he is playing FB, right? No.

I gotta disagree if what we're talking about is case management. That executive work is precisely why it's RNs that are the only ones on the nursing team who assess the patient. The assessment gathers the data we use to define needs and either meet them or ensure that they get met by someone else

Or maybe I'm not getting what you mean.

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canesdukegirl has 14 years experience and specializes in Trauma Surgery, Nursing Management.

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You know Erik, I agree with you on so many points. The highlight of my nursing career, when I felt the like I was delivering the MOST effective and the most needed care was when I was deployed to Katrina with my state medical assistance team. Nobody gave a hoot about care plans and time constraints. Nobody was whining about pt acuity or how many patients they had that day...we all worked as a team and served pts from all walks of life who had lost EVERYTHING. It was an eye opening experience and one that reminded me of why I went into nursing.

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eriksoln has 15 years experience as a BSN, RN and specializes in M/S, Travel Nursing, Pulmonary.

2 Articles; 19,508 Visitors; 2,636 Posts

I gotta disagree if what we're talking about is case management. That executive work is precisely why it's RNs that are the only ones on the nursing team who assess the patient. The assessment gathers the data we use to define needs and either meet them or ensure that they get met by someone else

Or maybe I'm not getting what you mean.

Eh, Case Management is nursing. So is nursing education. Both have patient contact. Case Management often talks to the patients (gasp........enter a dirty nasty pt room, my good, how do they survive in such a jungle) and provides education. Very often actually, a few times a day more often than not. One of the roles of a nurse, is Educator. Patients would not be able to make long term D/C decisions without their Case Manager involvement. No problem here calling that nursing.

Take Nurse Educators too. Might not be in the patient room or answering call bells..............but at more than a few facilities I've seen, the do pt. education on a number of levels. At my current facility, New Diagnosis diabetics get an education consult, and its the nurse educators. Lets face it, there is so much to learn in such a short period of time for these people, doing little quick 2min. teachings between med passes just isn't going to cut it. So, the Nurse Educator goes in, sits down with them for.......oh gee, an hour most of the time, and goes over the diabetic education with them. Also, at most hospitals, community education seminars that are open to the public are performed by the Nurse Educators. Again.........no problem calling that nursing either.

I'm painting with a very wide stroke/brush when I say your nursing must include some sort of patient contact. The people I described above.............while not necessarily performing clinical nurse bedside duties (answer call lights, put in foleys), at least have some form of pt. contact. I'd have no problem with the avg. case manager/nurse educator being a part of the "leadership" that shapes the nursing at my facility.

Hospital Supervisors and Unit Managers too. Some people would say they aren't nurses. They often decide what pt. is appropriate for what unit, have to mediate the more volatile complaints and all the while use management skills with an often unhappy nursing work force. No problem saying this is nursing. I'm happy when my manager is there to put out the trite fires of some pt. who can't be made happy, that way the care to everyone else doesn't slip.

I'm painting with a very wide brush/stroke when I say its not nursing unless you are at the bedside. I'm not saying you have to answer call bells or fill water pitchers. I'm just saying....................If you are not in some way/shape/form coming into contact with a patient and using your skills to make things better for said pt...................it might not be nursing that you are doing. If w/e you do doesn't benefit A PATIENT, directly, than..................you are probably doing something else for the employer.

The people I have a problem with are not the specialized sectors of nursing that have minimal patient contact. Its the Upper Management and Administration that irks me. Now, I know for a fact you've heard the term "Disconnected Management" or "Detached Administration".................everywhere on this board. I also know, here on this board and in R/L, the biggest complaint about the decision makers is.................."They don't get us, they are clueless as to what we do, how it should be done and what to do to make it better."

Point of my article is..............our decision makers are clueless like this becasue.......................OUR NURSING LEADERS, NURSES IN UPPER MANAGEMENT WHO REPRESENT US TO THEM............are poor examples of the nursing workforce as a whole. The biggest reason for this............because they are people who consider bedside nursing "remedial", or "tech duties" or "its for the people who can't do better." Never-mind that nursing is supposed to be about helping the patient at the bedside.............not making administrative decisions about how much to spend building the new parking garage.

Maybe that where some of the confusion with llg is, IDK. I am talking about completely detached from the patient care process nurses..........not nurses who have minimal clinical/bedside duties. I'm talking about DON's...........IDK the title for every hospital...........the UPPER MANAGEMENT/Administrative Nurses. Thats where we fall fall short/IMO.

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llg has 40 years experience as a PhD, RN and specializes in Nursing Professional Development.

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idk. maybe i do get you. there was a point where i considered putting in some disclaimers regarding how i've seen a great many non-bedside nurses act. is it my stance that if we remove bedside care from the nursing spectrum, that its no longer nursing that you don't like? this stance should not be interpreted as "unless you are at the bedside at least x times/week and answer y call bells/day, you can't contribute to nursing, so don't call yourself a nurse." i feel my explanation given to the other poster makes that point.

is saying the nurse who does not practice at the bedside is not actively nursing too far a stretch? i'm comfortable with it. i'm not saying they are not a nurse anymore or any less of a nurse, just that office work and paperwork are not "nursing". that has more to do with my attitude towards the paperwork that seems to dominate our day than with who can call themselves a nurse. guess what? when i am sitting at the nurse's desk, angry as heck cause i want this/that form done so i can go do "nursing", i don't feel like much of a nurse. thats where that comes from.

great post, eriksoln. i appreciate the thought that you put into it. i'd love to sit down, put our feet up, have "beverages of our choice," and have a face-to-face conversation. i'm sure i would enjoy it -- and i am pretty sure we could do it without getting nasty.

in fact, i think we are in 90% agreement. the only thing i disagree with is your stance that nursing activities that don't involve direct contact with the patient are not really nursing. a lot of nurses help groups of patients (populations) rather than focus on one patient at a time. that doesn't mean that they are not nurses.

when i was a student, i struggled to provide care for 1 patient.

when i was a new grad, i learned to take care of 2 or 3 patients at a time in the neonatal icu.

as i got a little more experience as a staff nurse, i became and excellent charge nurse -- able to see the bigger picture of running the shift, coordinating the work of multiple staff nurses, and making sure all the babies got what they needed. when i became a charge nurse, i didn't stop being a nurse just because i started looking at the bigger picture, the care of multiple patients, and the coordination of resources for the shift.

after i got my msn, i became a clinical nurse specialist. yes, sometimes i got involved in the care of particular babies. i also provided a lot of care for parents. but i also spent time developing policies and programs so that all the babies in the unit got the best care possible. i did a research project and published it, helping thousands(?) of babies get better care. did that make me less of a nurse? does that mean i wasn't focused on patient care? no! my focus was on helping the staff of that unit give the best care possible to those patients. if that mean touching the patient myself, i touched the patient. if that meant teaching a class, i taught a class. if that meant writing a budget so that we could get the resources we needed to give the best care, then i wrote a budget. it's still nursing because i was using my nursing knowledge to assess the patients' needs and doing what i needed to do to get those needs met. it is what florence nightingale would have done.

as we "climb the career ladder," get more education , etc. ... most of us try our best to maintain our nursing ideals as we slog through the very messy political, financial, and economic muck of the health care industry. few people strive for advancment to hurt the patients or the nurses on purpose. but some people do a better job of living those ideals than others. that's true of nurses at every level -- direct patient care givers included.

for those of us in leadership positions, actually delivering the resources to the bedside is getting harder and harder these days. the battles we fight every day in our jobs are ones the average staff nurse has no experience with. i understand that people come here to vent and that it is inevitable that they will complain about their jobs, their managers, etc. but don't say that nurses who focus on providing services to populations of patients are not nurses anymore just because they help many patients at the same time rather than just focus on 1:1 care. that's not fair -- and we will respond to such comments because they strike a nerve.

we are all nurses because we are still assessing patient needs and working to see that those needs get met. we are just focusing on groups of patients (populations) rather than individual patients one at a time. and when you focus on groups of patients, the daily tasks that you do are different. instead of starting an iv, we research the best practices for iv starts and make sure that our staff is providing those best practices -- and that the supplies they need to do it are available, etc. instead of providing physical care for that patient in the bed waiting for transfer to another facility ... we are trying to find an available bed for that patient at an institution that fits the family's needs and ability to pay.

it's still nursing. that's my point -- and that's how it relates to the other thread. when you say that i am no longer practicing nursing because i am not a bedside caregiver anymore ... that's like the insults being discussed in the other thread. when you say that i am not a practicing nurse, you are insulting all of us who work hard to provide the nursing services that the poplulations we serve need. you are saying that florence nightingale was not a nurse for most of her career. you are saying that anyone who wants to become a leader of nursing has to "leave nursing" to do it -- that the very acts of leadership are not consistent with "true nursing."

that attitude keeps nursing down -- because most nurses cherish nursing -- and we need to make is socially acceptable within nursing to be a leader. when we put down all of our leaders as a group, saying that only the bedside nurses are "true nurses," it paints a negative picture of leadership -- and that negative perspective will tend to discourage people from pursuing leadership knowledge and roles. we need leaders, good leaders -- and we are not going to get them if the profession disowns all nursing leaders as "not really nurses anymore."

Edited by llg

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Kevin RN08 has 2 years experience and specializes in Med-Tele, Internal Med PCU.

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I agree and understand much of what you are saying. And I would encourage more managers to come back to the trenches once in a while. It's like the "Undercover Boss", these CEOs normally walk away with a deeper appreciation of the work their employees do, how their policies effect the work and workforce.

When I was an aide, my NM and the Educator would frequently (3-4 times/week) come on the floor during AM shift change and/or during lunch to help care for patients. They would help get water, toilet, clean-change, administer pain meds. We loved them for it, it also allowed them to get DIRECT feedback from the patients. The NM had scrubs in her office, if we were short handed she would work the floor AND attend her meetings.

Where I am now, not so much. We have an Clinical Nurse Educator who doesn't leave her office, but will call you in because you forgot to chart a pain REASSESSMENT (sorry I was running a code ... on HER). The NM is routinely off the floor in meetings, writing evaluations, reviewing & submitting reports, setting policy, dealing with personell matters, it is all important stuff and in her defense it is a MUCH larger organization, but it is Business Administration not Nursing. We don't see her with her "Nurse Hat" on and that is where the rub is.

I've worked nights here for a year and a half, ONCE the NM worked with us. Once recently the CNE told the offgoing Charge that the oncoming Charge would just have to "suck it up" when the day staff was 2 people short ... the oncoming charge had not finished her orientation!

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nursemike has 12 years experience as a ASN, RN and specializes in Rodeo Nursing (Neuro).

1 Article; 14,755 Visitors; 2,345 Posts

Interesting thread. Like the OP, I've come around a good deal on the "profession" thing. Like the OP, I'm frustrated by the bureaucratic obstacles that impede direst patient care. And I'm deeply offended by those in whatever role who look down on staff nurses. My thoughts on who to blame and my thoughts on what constitutes nursing have become a bit more amorphous, though, now that I've been doing charge for awhile.

At my facility, the CN is optimally a "free" charge, with no direct pt assignment. I alternate weekend with another nurse, so we're each in charge a third of our shifts, and happy for two-thirds. I haven't resigned from the charge role, mostly because I hate being a quitter, partly because I think I might be able to do the other staff nurses some good, partly because I cling to the hope I might get good at it, eventually. (When I started this, I told a newer nurse I was a lot like her, in that I was still learning my job, but that I had the advantage of having survived what she was going through. Once you've survived your first year as an RN, it takes a lot to scare you. And it's true, or at least tru-ish, but I now find myself in the position I did as a second-year nurse, busting my tail to get things done that a year ago I didn't even know I was supposed to do.) I am deliberately omitting the distinct possibility that I'm still doing charge because I'm stupid. You can't fix stupid, and I'm too busy for things I can't fix. Maybe it's progressive, and I'll eventually be too stupid to know I'm stupid. So, you know, something to hope for...

So, when I'm a staff nurse, getting report from another staff nurse who tells me pt x got educated, so CN xxx won't be bringing around those cursed little post-its, I can honestly commiserate, yeah, I hate those post-its. And then, later, sometimes, I'm getting my own post-it because my predecessor forgot to click on tab out of, like 73, to document that the education was done. But at least it's better than being the one handing out the infernal little...but I digress.

I've been appalled and amused at some CN meetings, wherein mgt speaks to us as though we were one of them. Well, I'm usually in the back, with my hat over my eyes, so they might not mean me. But, one of the ideas that led me into this pit was the idea that I might learn some things doing charge, and it turns out I was right. In making other nurses' assignments, I think I've had some useful insights into my own bedside practice. Oh, she usually deals really well with that sort of patient. Hmm. Why is it she deals so well. What can I do that she does? Or, conversely, if I give this one that pt, she'll likely kill him. What's wrong with her? What do I need to avoid, or to remember? And, sometimes, I can even remember how to prevent getting one of those freakin' post-its!!!

But, Dear Lord in Heaven protect me (and I really mean it, this time, not being sacreligious as usual) I'm also learning to see some things from management's side. So, I still believe, and always will, that without bedside nurses, a hospital is just a really crappy hotel, but I'm increasingly getting that if JCAHO shuts us down, or even if we go bankrupt, we won't so much be bedside nurses as unemployment line nurses. (Which, I hear, means even more red tape.) So now, as my coworkers and friends are running around trying to do their first assessments and pass meds, I'm handing them godforsaken sticky papers of death to please chart some education before midnight, because it has to be documented at least Q24. Please. Just do stroke education. No one has done that, yet, because they're here for pancreatitis. They're probably at risk for stroke. Who isn't? Hell, I'm about to have one. Reinforce the TV channel guide, if you must. As long as you get that box clicked before midnight, you can think about something that makes sense, later. And if you happen to document that, dayshift will love you. Yeah, I know--ungrateful wretches.

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13,275 Visitors; 2,801 Posts

Thanks everyone for sharing! I must admit I still tend to want limit the concept of the *practice* of professional nursing to direct patient care. A nurse engaging in case management or infection control may draw upon nursing knowledge and apply nursing principles, but does that necessarily mean that they are *praticing* nursing in that role? A case manager is also going to draw upon medical knowledge and apply medical principles in determining pt needs and plans; they are not professionally *practicing* medicine are they? Similarly, a practicing nurse constantly draws upon medical knowledge and applies medical principles, but is not practicing medicine, right? I'm also thinking that a physician in a public health or lab research is not *practicing* medicine *in that role* even if the reason that have that role is because they *do* have experience practicing medicine. Does that make sense?

I agree that its a nurse's professional obligation to provide education. I also think it is physicians' professional obligation as well. And lawyers and accountants. All professionals should ensure that their clients understand what's going on. Do all do that well? No. Not all nurses are great educators, either. Heck, not all professional educators are great educators!

My point is that a nurse who is educating is not *practicing* nursing when educating, though they most certainly are still professional and still a nurse! At that point, they are nurses who are educating as part of their professional obligation; same as when a lawyer explains things to their client, they are not *practicing* law in that moment. What about patients who need extensive education in regard to their health condition, such as a new diabetic? A non-nurse diabetes educator with 10 years experience will probably be a much better resource that any 'just-off-the-street' nurse without any specialized diabetes experience.

One more example, let's say the diabetes educator role at a facility specifically involves professional clinical assessment that necessitates a licensed provider to fill the role. Couldn't a physician theoretically take such a role as well? Certainly, many wouldn't be well-suited to such a role, but there are also nurses out there who wouldn't be well-suited to the role of diabetes educator. So in the *same* role, would a diabetes nurse educator be practicing nursing while the diabetes physician educator is practicing medicine?

Edited by jjjoy

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eriksoln has 15 years experience as a BSN, RN and specializes in M/S, Travel Nursing, Pulmonary.

2 Articles; 19,508 Visitors; 2,636 Posts

Oui Vay:uhoh3: My head be spinning right now. And, honest, even though I'm on vacation right now, I'm not drinking.

Love your posts Mike. Actually, it was your last post in the orig. duck thread that made me think harder about whether true "theory" existed for bedside nursing. I think it does, to a degree. And what doesn't, is bound to show it's head eventually as some very bored, retired nurse sits down and writes it. :p

I'm going to the gym. Maybe some cardio will help the head spinning stop.

Oh. BTW. Love your post too Jjoy. I actually think your explanations are better than mine. And they certainly raise some questions. As did llg's post.

Hmmmm...............while taking Jjoy's post into consideration, what does one say about the nurse, working from an administrative position who: With his/her position and closeness to decision makers, convinces admin. that a new set of protocols (unit specific) that will save time for the nurses should be invested into? Lets say these protocols work, with no hitches, and pt's see more of nurse as a result. Did they practice nursing? They directly affected a patient for sure, and you could say they affect more pt's than I do as a bedside nurse taking care of my alloted ratio each day, as their system will effect pretty much every pt. that comes in the door. Probably, no........certainly had to use nursing judgement to know if they were actually going to work and recognize the value in saving bedside nurses time. So..........call it nursing or call it administration with a nursing background? That's a though one, takes people smarter/wiser than me to answer that one I guess.

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