Too much emphasis on "caring"

HouTx, BSN, MSN, EdD · Sep 7, 2012

I applaud everyone's passion on this issue. But in the US, there is zero chance that nursing services will be billed separately because future reimbursements are moving into 'outcome' based mode - whereby everyone who participates in the care will have to share a lump sum - and that amount will be adjusted based upon how well the service was delivered, the quality of the outcome - and (ta da!) how well the patient liked everything. Rest assured that this state of affairs is not going down well with physicians either, who have been used to billing the patient whatever they choose. But our current situation has just too many fingers in the pie and our care delivery systems are struggling to survive under the increasing juggernaut of paperwork that is required to support our financial hairball. It has to be simplified.

Keep in mind that Nursing care=hospital care. The only reason that patients are admitted to inpatient status is because they require continuous nursing care. "Room charges" are currently based upon all the 'stuff' that supports that stay, including nursing care. The problem is that nursing has never been viewed as a revenue center by the powers that be or accurately quantified in a meaningful way that can be confidently applied .... so they are at liberty to mess with us however they please - whether it is reducing the number of RNs or ratcheting up the workload. In actuality, nursing is the primary revenue center - because the need for our services is what drives admissions.

I'm as old as mud, and have been a nurse for plenty-one years which gives me a bit of perspective. Every few years, the "charge for nursing care" issue bubbles up in popularity but dies down again due to lack of follow-through. Only in the last decade has there actually been any clear evidence of the role of nursing care in determining health care outcomes. Thanks to the work of nurse researchers/leaders like Linda Aiken and Tim Porter-O'Grady, we finally (!) are accumulating sufficient information to affect legislation and policy. But you know the drill - it takes ~ 17 years for research findings to actually be integrated into business practice. So - maybe next decade?? I hope all of you young ones will finally benefit. (fingers crossed)

llg, PhD, RN · Sep 7, 2012

You don't need to really care (in a touchy-feely way) to be competent. Give me a cynical, world weary battle axe who knows her stuff over a Florence nightingale who's an airhead any day.

Uhhh.... Florence actually was a "battle axe who knew her stuff" -- and who fought the system to achieve change. One of the first things she did upon arrival at Scutari was stage a little strike in favor of better working and living conditions for the nurses.

This post just shows how much many nurses DON'T know about nursing history and the leaders of the past. That lack of knowledge (all too common in nursing) is one of the main reason contempory nurses NEED to study nursing history and theory. Too many nurses have forgotten -- or never learned -- of their true professional heritage and have betrayed that heritage by becoming "handmaidens" and "victims." That's not what our previous leaders have been -- or wanted for us.

Edit: I wrote this before seeing your apology, Brandon. Thank you for recognizing that you made a mistake.

llg, PhD, RN · Sep 7, 2012

I like where this thread has lead ... to a discussion of how important it is for nursing to engage in nursing philosophy and theory and research to clarify and document our role and worth in society. If we don't do that, we run the risk of be "run over" by other people who have their own agendas. We need to know who we are, what we do, and why we are worth paying for -- and we need to communicate that to society.

That's really what nursing theory and philosophy is all about. Collectively, nursing philosophy and theory are the "conversation" we have within our discipline about those issues. And those things should evolve as conditions within society change. That's why each generation of nurses must study these things and add it's own perspective to that on-going conversation.

To the OP: I am sorry that you chose a school whose curriculum/faculty are not meeting your needs. Different schools (and different faculty members) have different slants -- and there is probably a better fit somewhere else for you. Is it too late for you to change schools? Or do you just have to "suck it up" and finish so that you can move on to the next stage of your career? If you need to stay in your current program, can you find a friendly faculty member who would be sympathetic to your plight who could mentor you within that program? Your questioning about caring theory would be welcomed in my theory class. Not every faculty member is alike.

merlee · Sep 7, 2012

The last time I spoke out, I became targeted for firing, and they managed it in 7 weeks. Totally broke me emotionally and financially.

So hard to not have anyone to PUBLICLY back you. Didn't help me when everyone agreed with me AFTER the meeting - no one spoke up during the meeting. So I was the lone dissenter.

My manager was forced to write me up, and to fire me, with the threat of her own job. She cried when she was firing me, even the HR manager knew the 'real' reason had nothing to do with the level of care I was giving.

sistasoul · Sep 7, 2012

Maybe the hospital room rate should be based on the patient's diagnosis and other chronic issues? The problem I can see with this is that a lot of the times it is the middle aged and younger folks who take a toll on nursing due to a sense of entitlement.

Also, if you speak out and upset the applecart you will be disciplined as being disruptive to the floor as the above (merlee) stated. We are treated as children and get written up.

mazy · Sep 7, 2012

I agree with others. I always thought that Florence Nightengale was the ultimate battle-axe. Along with Mother Teresa. I think sometimes people see these women as fluffy, cloud-like, angelic creatures who moved mountains with their love and compassion alone.

But I think about what they were up against and I imagine they had to have been tough as nails, driven, true warriors to get anything done.

It frustrates me so much when I hear people say "nurses are supposed to be compassionate" as if that means we are soft and malleable and will sacrifice our own personal well-being just to make sure people get what they want.

And that is the way I learned about nursing theory.

In fact the opposite is true, that we are advocates for our patients, and advocating is a fight, and the fight can be bitter. Nurses need to be able to identify the real problem areas in the system that get in the way of providing patient care, along with tactics for overcoming those problems without becoming sacrificial lambs to the system.

It seems to me that when teaching nursing theory, schools would better serve us by focusing on what those principles can teach us about how to advocate for patients and ourselves in a system where everything seems to be an uphill battle.

Teach us how to be strong and effective in a way that doesn't destroy us.

If being caring and compassionate were easy, everyone would be doing it and this would be a very different world.

emdrn74 · Sep 7, 2012

"Teach us how to be strong and effective in a way that doesn't destroy us."

AMEN! We are a unique population and there has to be a way of empowering us without killing our spirits. What a great topic and thread. Thank you all for my" food for thought" of the day:) It's nice to know I'm not alone.

PennyWise · Sep 7, 2012

I too have been annoyed by the theorists who spew on and on about "caring". Its as if they all wrote their work after a very long separation from the profession. The theories simply did not apply to nurses doing direct patient care it seemed, and they were not practical at all.

Much later, I find myself with a new attitude towards some of the specific theories and nursing theory overall. Part of the reason for my change of heart is my new way of defining "care".

"Caring" is not a static word or action. Think back to your Psych 101 class to get my jest. Every PSY101 class begins the same way, with the question: "What is normal?". Most people struggle giving it a concrete description that holds up in different settings/situations. Apply the same train of thought to "Nursing Care". What is it? When are you doing nursing care and when are you doing "other tasks" or "paperwork"? Its hard to come up with a description that holds up long.

Why? Because what "care" is changes with the patient's needs and what they face at the moment. I used to work on a M/S unit, and a fair share of my patients needed little more than their meds and help getting to the bathroom. Now, if I am out at the desk documenting and discussing things with the Case Manager/Social Worker while this patient needs to get into the bathroom, I'm not "caring" for the patient. On the other hand, once my patient is done having their elimination needs met, if I go out to the desk and spend the next half hour checking on the status of my Fantasy sports team, I'm not "caring" for the patient. I could instead be addressing the plan of care, documenting so that care can follow a well informed continuum and anticipating discharge needs. If the doctor holds their discharge because they don't know the patient has been voiding and this is a direct result of my lack of documenting, I have not "cared" for the patient. Then again, if my patient is having an active MI and I choose to run to the computer to chart that AM's output.................you know what goes here.

Gene Watson's theories were brought up, and I am a fan of hers now. I used to bash her relentlessly though in school and as a new nurse. If you apply my changing/conforming definition of care to her theories, she is much more palpable. Her thoughts on "therapeutic touch" are what kill her in my opinion. They give the rest of her theories a sense/feel of "lovey/touchy" that was not intended. When you read her theories with those tinted glasses, it can seem that her theory dummies down nursing and anyone who can "koochie koochie" their patient is a good nurse. I think we can all agree that is not the point Watson was making.

Instead, I take her theories as being a call to arms. She realized the importance of a therapeutic relation between a caregiver and a patient. While administration and business directed administration attempt to pile more and more work on nurses, the amount of quality time spent with patients is reduced. Since there is "no money to be made" in quality patient relations, this is a sacrifice they are more than happy to make. The politicians and policy makers see this trend and have taken action to better direct healthcare facilities, but more time is needed before their efforts bear fruit. Watson realized that a person to person relation, applied under the guidance of the proper vision of "care", is necessary for health and improves outcomes. It is our burden to take this knowledge and use it to further nursing as a profession. We have not done so........yet.

Another poster talked much about how technology and UAP are taking over nursing and phasing us out. I disagree. Most facilities I know of who have gone to such measures have reversed field by now. It just never works out. I don't think it ever will either. What I talked about above is why. Machines can not achieve a therapeutic relation with their patients. Bots who take vitals can not express any concern for the patients well being or assess changes in the patient's condition that require a change in the plan of care. Computers deciding when the patient's condition changes and informing/calling doctors? LOL, well, considering that they can't even develop a tire pressure gauge that is reliable enough to inform us when to check the tires, I don't think we're as close to this as you seem to believe. You think doctors flip out now about unnecessary/improper phone calls, oh my.........wait until they try to let a computer do it and see what results you get.

llg, PhD, RN · Sep 7, 2012

It seems to me that when teaching nursing theory, schools would better serve us by focusing on what those principles can teach us about how to advocate for patients and ourselves in a system where everything seems to be an uphill battle.
Teach us how to be strong and effective in a way that doesn't destroy us.
If being caring and compassionate were easy, everyone would be doing it and this would be a very different world.

Some schools DO teach nursing theory that way. Years ago, I went to such a school and try to teach my students that way now. Philosophy is one of the things student should look at when choosing a school -- but very few do. Most people just choose the most convenient or cheapest school to get the letters they want after their names.

VICEDRN, BSN, RN · Sep 7, 2012

Its like I told a patient the other day: Caring is a complicated concept and after a few years in nursing, I have realized that it doesn't mean getting involved with every single patient. Sometimes it means walking the HECK AWAY! And sometimes caring for one patient means advocating for another one instead...nursing should focus on something else, like professional development and autonomy.

mazy · Sep 7, 2012

I too have been annoyed by the theorists who spew on and on about "caring". Its as if they all wrote their work after a very long separation from the profession. The theories simply did not apply to nurses doing direct patient care it seemed, and they were not practical at all.
Much later, I find myself with a new attitude towards some of the specific theories and nursing theory overall. Part of the reason for my change of heart is my new way of defining "care".
"Caring" is not a static word or action. Think back to your Psych 101 class to get my jest. Every PSY101 class begins the same way, with the question: "What is normal?". Most people struggle giving it a concrete description that holds up in different settings/situations. Apply the same train of thought to "Nursing Care". What is it? When are you doing nursing care and when are you doing "other tasks" or "paperwork"? Its hard to come up with a description that holds up long.
Why? Because what "care" is changes with the patient's needs and what they face at the moment. I used to work on a M/S unit, and a fair share of my patients needed little more than their meds and help getting to the bathroom. Now, if I am out at the desk documenting and discussing things with the Case Manager/Social Worker while this patient needs to get into the bathroom, I'm not "caring" for the patient. On the other hand, once my patient is done having their elimination needs met, if I go out to the desk and spend the next half hour checking on the status of my Fantasy sports team, I'm not "caring" for the patient. I could instead be addressing the plan of care, documenting so that care can follow a well informed continuum and anticipating discharge needs. If the doctor holds their discharge because they don't know the patient has been voiding and this is a direct result of my lack of documenting, I have not "cared" for the patient. Then again, if my patient is having an active MI and I choose to run to the computer to chart that AM's output.................you know what goes here.

I think you have made a really good point here. Reminds me of the dilemma anthropologists face when observing cultures -- do the behaviors of the cultures change as a reflection of the observation, do the observers change as a reflection of the cultures observed?

It's hard to identify a pure concept of what care means in nursing, with so many people involved, and to separate the subjective ideas of caring for x or caring about x, or even being cared for, from the objective, tangible tasks of providing care.

Because nursing, at it's core, is about disparate individuals interacting with each other; and what happens when people interact is that they change.

And for nurses, that means that everything we do changes everything. All the time.

It's exhausting to think about or to try and keep up with it.

It's also a good reason that computers will never be good nurses.

sweet~revenge · Sep 7, 2012

Wow, thanks for all the great replies. Many great points made here. I thought for sure I was going to get flamed.

The problem is that nursing has never been viewed as a revenue center by the powers that be or accurately quantified in a meaningful way that can be confidently applied .... so they are at liberty to mess with us however they please - whether it is reducing the number of RNs or ratcheting up the workload. In actuality, nursing is the primary revenue center - because the need for our services is what drives admissions.

Exactly. That's why I say nursing is a necessary evil to hospital administrations. They need us to continue churning out revenue but they don't see us as producing profits. We're just a big money sink to them so they stretch us to the limit and then some.

I'm as old as mud, and have been a nurse for plenty-one years which gives me a bit of perspective. Every few years, the "charge for nursing care" issue bubbles up in popularity but dies down again due to lack of follow-through. Only in the last decade has there actually been any clear evidence of the role of nursing care in determining health care outcomes. Thanks to the work of nurse researchers/leaders like Linda Aiken and Tim Porter-O'Grady, we finally (!) are accumulating sufficient information to affect legislation and policy. But you know the drill - it takes ~ 17 years for research findings to actually be integrated into business practice. So - maybe next decade?? I hope all of you young ones will finally benefit. (fingers crossed)

You're exactly right, I was shocked to find out that there's been no real research on the role of nursing care on patient outcomes. Like you say, at least someone has started producing some research on it and hopefully we can use it to our advantage. Thanks for letting me know about Aiken and O'Grady, I would like to learn more about them.

This post just shows how much many nurses DON'T know about nursing history and the leaders of the past. That lack of knowledge (all too common in nursing) is one of the main reason contempory nurses NEED to study nursing history and theory. Too many nurses have forgotten -- or never learned -- of their true professional heritage and have betrayed that heritage by becoming "handmaidens" and "victims." That's not what our previous leaders have been -- or wanted for us.

This is very true. Florence Nightingale has been made into some frou-frou la-di-da angel when in reality she fought tooth and nail in a man's world to make nursing a respectable profession. She was a mathematician who used statistics and research to produce measurable outcomes on illness. If we had more nurses like her, we wouldn't be in the position we're in today.

History is important, but I want to see more nursing education about science, the economics of health care and how to bring about policy changes. If it was expected that to be a nurse you were going to also take part in change, be willing to have the strength to stand up and let your voice be heard, it would change the tone of nursing. Imagine starting your nursing education with this message woven throughout and I think it would make a big difference in the future of nursing and would produce more nursing leaders.

To the OP: I am sorry that you chose a school whose curriculum/faculty are not meeting your needs. Different schools (and different faculty members) have different slants -- and there is probably a better fit somewhere else for you. Is it too late for you to change schools?Or do you just have to "suck it up" and finish so that you can move on to the next stage of your career? If you need to stay in your current program, can you find a friendly faculty member who would be sympathetic to your plight who could mentor you within that program? Your questioning about caring theory would be welcomed in my theory class. Not every faculty member is alike.

Thank you. To be fair the professors seem to be fair, open minded and truly interested in helping students succeed. I didn't mean to make it sound otherwise. I also like this program because it offers some graduate classes that bridge to an MSN and I like the fact that it's a respectable school with a real address, not one of these fly-by-night 6 month online programs. You're right, there are always different slants to different classes and instructors. Discussion is encouraged and I've talked about some of these issues, but part of the problem is that I feel like a lot of the other students are there just to get through it. If I can make a difference in one other person's way of thinking, at least that's something.

The last time I spoke out, I became targeted for firing, and they managed it in 7 weeks. Totally broke me emotionally and financially.
So hard to not have anyone to PUBLICLY back you. Didn't help me when everyone agreed with me AFTER the meeting - no one spoke up during the meeting. So I was the lone dissenter.
My manager was forced to write me up, and to fire me, with the threat of her own job. She cried when she was firing me, even the HR manager knew the 'real' reason had nothing to do with the level of care I was giving.

Thank you for speaking out. I'm sorry that you had such a horrible experience, I know exactly what you mean when you can't get anyone to make a stand with you. It's so frustrating. I hope you're at a better facility now. I've written incident reports about short staffing before, I regularly speak out when short staffed, am on a staffing committee where I work, and not only have I never been written up but I got approval to transfer into ICU earlier this year. My current director knows me well from previous meetings so it's not like she didn't know who I am. I'm at a union facility so that helps, but administration is very hostile and even with a strong union there are still nurses afraid to say anything for fear of losing their jobs. They have fired a couple pro-union nurses before but they were able to get their jobs back because it was a clear case of union retaliation.

You know what? I decided a long time ago that they can fire me if they want to because I will not become so afraid of losing a job that I lose my self respect and let them walk all over me. So again, thank you. You made a difference whether you realize it or not.

I agree with others. I always thought that Florence Nightengale was the ultimate battle-axe. Along with Mother Teresa. I think sometimes people see these women as fluffy, cloud-like, angelic creatures who moved mountains with their love and compassion alone.
But I think about what they were up against and I imagine they had to have been tough as nails, driven, true warriors to get anything done.
It frustrates me so much when I hear people say "nurses are supposed to be compassionate" as if that means we are soft and malleable and will sacrifice our own personal well-being just to make sure people get what they want.
And that is the way I learned about nursing theory.
In fact the opposite is true, that we are advocates for our patients, and advocating is a fight, and the fight can be bitter. Nurses need to be able to identify the real problem areas in the system that get in the way of providing patient care, along with tactics for overcoming those problems without becoming sacrificial lambs to the system.
It seems to me that when teaching nursing theory, schools would better serve us by focusing on what those principles can teach us about how to advocate for patients and ourselves in a system where everything seems to be an uphill battle.
Teach us how to be strong and effective in a way that doesn't destroy us.
If being caring and compassionate were easy, everyone would be doing it and this would be a very different world.

Couldn't have said it better myself!