What Happened To The Nursing Profession?

[Anxious Patient]

As a non-health care provider, I don't understand this doctor's complaint about nurses, as it's beyond my scope of knowledge. But I'm sure there will be rebuttals from some of you here.

One of my biggest irks about the nursing profession is their failure, at times, to use critical thinking skills. Some nurses are much better than others. Some floors are much better than others and in fact, some floors I give rock star status. I would trust them with my life to do the right thing. And then again, some nurses are incapable of comprehending what critical thinking is. I'm not sure if this is because of the rules and regulations by the hospital or government imposed safety regulations or simply something that isn't remembered from their school days or even that it isn't taught anymore (a scary thought).

What happened to critical thinking in the nursing profession? Is the nursing profession to blame for turning some nurses into robotic like documenteurs, void of any critical thinking skills? Or is it the toxic malpractice environment that drives robotic like activity?

http://thehappyhospitalist.blogspot.com/2009/03/what-happened-to-nursing-profession.html

[Valerie Salva, BSN, RN]

I think there are mutiple factors contributing to lack of critical thinking among many nurses.

First, there is the mgmt of healthcare being taken over by business people- bean counters and the whole customer service mentality.

Nurses are instructed and pressured to do stupid things like scripting- "I have the time" hourly rounding and charting and so on.

If a nurse spots and does not carry out an inappropriate MD order, mgmt probably won't know about it and nothing will be said to her. However, if the nurse does not smile enough at Joe Blow and does not get him another pillow and a soda fast enough, or gives a med "late" they will know and the nurse will hear about it.

Too many duties and tasks that used to go to ancillary services now rely on nursing to get done. When nurses are doing things such as emptying trash cans, stocking supplies, picking up lunch trays, etc. they are forced to be task oriented- they are not looking at or thinking about the pt when they are doing these things- they are thinking about the clock, lack of time, and crossing another item off of their massive "to do" list.

Short-staffing- When units are purposefully short-staffed, nurses are forced to run around like chickens- there is no time for reflection- no time to look through the chart, no time to stop and think for a moment- "Hmmm....this pt is having this symptom... is it a side effect of a med or something else?"

Simple lack of knowledge- I dialyze a number of pts who live in rehab nsg homes and who also have liver failure. When I ask the facility to fax me their MARs, I often see that these pts are on routine Lactulose (to cause diarrhea in order to lower the pt's ammonia levels). However, I will see that the nurses are holding the Lactulose, and giving the pt Immodium. They just don't know enough about these pts' DX and what goes along with it.

Nurses need to think like a careplan: liver failure pt> low protein diet> routine Lactulose> frequent loose stools>high risk for skin breakdown>need for frequent toileting>excellent skin care required>may have low bps> ^ risk for falls>moniter for changes in LOC & cognition>moniter for SOB.. and so on.

I think that a lot of nurses are reactive- they react to pt s/s rather than anticipating & expecting them. I would much rather spot potential fires and prevent them that run around putting fires out.

This is due to lack of knowledge, but also lack of time and sufficient staff so that nurses can take a moment to think and prepare.

Nurses do not educate themselves-

Here is an example. I work opposite days with a nurse right now who often loudly critisizes me and the things I do. She does not understand why I do some things. Well, my dialysis pts do not cramp, vomit or crash on tx. Hers do.

After I received my basic dialysis orientation, I started reading articles about dialysis and renal pts. I could observe the things I'd read about in my pts and learned what to do to prevent problems and improve pt outcomes. I subscribe to newletters. I buy and read books about dialysis. This other nurses does not.

After she completed the very basic company provided dialysis orientation and training, she was done with her education. She felt she knew enough about dialysis and just went with it.

I did not. I continue to learn and seek out knowledge about dialysis.

Mgmt loves this nurse, though, because she is great at paperwork. However, the pts tell me "I'm glad you're here. I know I won't feel bad after my tx."

This nurse is complemented on how fast and efficiently she gets her pts to the ER. I have not received such compliments, because I work to prevent my pts from needing emergency tx in the first place.

Additionally, I think that because of the so-called "shortage" a lot of people who really do not have an aptitude for nursing pursue it because they think it's a "cool" job with "big bucks and lots of jobs."

I also think that schools are lowering standards and allowing people to graduate who really shouldn't.

[RNperdiem, RN]

I see the bell curve theory.

At one end are the superstar performers. Their numbers are small, they are amazing to work with, and succeed in all endeavors.

At the low end are the nurses who you are surprised passed their exams, are unteachable, unreachable, and dangerous.

Most nurses are in the middle. Good teaching, precepting, and high standards go a long way. Critical thinking can flower in the right environment.

[schroeders_piano, RN]

I think Valerie Salva hit on something in her post when she said some people are pursuing nursing because it's "cool" or they are in it for the bucks. I work with far too many nurses that they are only concerned about coming in and getting their job done so they can go home. They don't grab a chart and maybe read the H&P. They don't know what meds their patients are on other than the ones that they have to give that night. They don't have a clear picture of what is going on with their patients.

I also think in an effort to get more nurses on the market for the supposed "nursing shortage" colleges expanded too much. My graduating class had 18 in it. Our instructors knew what areas we were weak in and were able to focus on that with us. It made us better nurses. The nursing program I was in, now takes in 60 students a year instead of the 20 like they use to when I was in the program. They can't focus on every students weakness anymore. The instructors are awesome, but the nurses coming out of that program are no longer on the same caliber they once were. I can say the same about other nursing programs in my area.

[hypocaffeinemia, BSN, RN]

I could say the same thing about the doctors,some are "C" doctors and some are "A" doctors.

How about a doc who prescribes a synthroid to the patient who JUST had a heart attack and this drug should not be taken after recent MI,is that a critical thinking?

Your post demonstrates the type of black and white mentality the blogpost addresses. While indeed, an acute MI is listed as a contraindication to the use of levothyroxine, there may be a legit reason for its prescription. I can easily see a physician restarting thyroid replacement for someone with little to no thyroid function if the patient, post MI, is in a generally stable state. Of course, its use would need to be monitored closely, but you can't merely decide not to replace such a patient's thyroid function unless you are a fan of myxedema, severe bradycardia, and all the fun stuff that goes along with it.

[1TachyRN, RN]

I agree with the doctor. There are just those people who lack common sense and shouldn't be nurses.

[morte, LPN, LVN]

I think what the problem is, is that doctors don't realize that for the most part, nurses aren't allowed

to sneeze without a doctor's order.

Seriously though, there are a lot of interventions that requre a doctor's order, that doctors feel shouldn't require an order. So they get mad when the nurse calls them for an order.

I think I can still see where the doc is coming from though. Doc's appreciate it when you have examined the situation thouroughly, have already come up with what would probably be the best solution, and THEN call them for the order, instead of calling them in a panic "what should I do, Dr. Jones??" whenever you have a patient that can't pee.

yup, other than "standing" orders, nurse's hands are pretty much tied......legally speaking......and IF you do something logical, but the doc has a hair-across-his-orifice......you can be in deep organic fertilizer

[JustMe]

"I think what the problem is, is that doctors don't realize that for the most part, nurses aren't allowed to sneeze without a doctor's order."

AMEN! It seems as though nurses aren't nurtured into an independent thinking role. As a cardiac nurse, I may want to give my MI patient (who has a history of gastritis) an enteric coated aspirin instead of the uncoated aspirin. But I cannot make that substitution without an MD order. Excuse me??? What the h*** is the difference between the two except the coating?? And possibly a few pennies. As far as evidence-based practice goes, the only diagnosis that calls for an UNcoated aspirin is an acute MI.

As a clinical instructor I'm doing my best to foster critical thinking in my students. But it's difficult when the nurses on the floor complain that my students didn't give baths or the CNAs disappear into the woodwork when they know there are students on duty. The whole acute care atmosphere these days DOES NOT allow for independent thinking from Doctors or Nurses. We're practicing cookbook medicine.

[NeosynephRN]

I cannot even count the times I have been told by a Doc.. "I am transfering this pt to the ICU, because I know you will not freak out and call me every ten minutes, you will use your heads and do what needs to be done."

However I am not sure if I had 8-9 patients I would have the time or energy to think...we need reasonable nurse patient ratio's on the floors, cause even the greatest nurse in the world could miss a subtle change on one of nine....

[WalkieTalkie, RN]

As a clinical instructor I'm doing my best to foster critical thinking in my students. But it's difficult when the nurses on the floor complain that my students didn't give baths or the CNAs disappear into the woodwork when they know there are students on duty. The whole acute care atmosphere these days DOES NOT allow for independent thinking from Doctors or Nurses. We're practicing cookbook medicine.

No kidding. Who gives a rat's behind if we can make a bed "properly" or not? I'll admit my bed making sucks, but that was a huge focus for the first couple of semesters in nursing school. Honestly, I don't care how my bed looks as long as it's free of wrinkles and is reasonable shape for the patient's needs. Do you know how many times I have done mitered corners since nursing school? ZERO. I have yet to meet a patient who complained about my lack of having them.

We need to focus more on critical thinking and less on ho hum boring and nonsensical things, like how a bed looks, or if a nursing student can do a bath... honestly, it's not that difficult! Once you've done a few, you really get the hang of it, and it's not too hard to figure out to begin with.

Let's spend more time thinking of other things, like "Hmm... should I really give this guy 50 mg of PO Lopressor when his BP is 86/50?... Oh wait, I need to make that bed!" Yeah, how many times have I seen that happen because people don't put 2 and 2 together? I'm far more worried about my patient's condition than how their bed looks, but for some reason, we seem to focus on these ridiculous things.

[Miss Mab]

His blog topic and rationale lack evidence of basic critical thinking......this from someone who usually enjoys that site.

Why harp on 'critical thinking' in relation to an area where most have no choice whatsoever to pick and choose which facility policy they will deem to follow based on their own (granted reaaallly basic sometimes) knowledge? What does this have to do w/one's intelligence or lack thereof? Is he really that clueless as to the environment many of us are working in?

IMO, general lack of awareness, and also apparently the lack of even the tiniest initiative it would have taken to investigate this particular example of staff shortcoming, is more a reflection on the poster than the nurses he's been forced to work with. The real insight failure is by those who somehow remain oblivious to the forced charting, rote roles and scripting that now permeate nursing practice and whose ever expanding existence basically shuts out what little room might have ever be left to allow for our own 'judgement'.

Are schools graduating 'dumber' nurses these days? I don't know but yay for all of of the nursing professionals both here and on that site that are seemingly inspired to pile on with their own generalizations of why nursing is growing ever more stooopid. We are our best PR, afterall...Are there valid criticisms about where things stand now that are actually within nursing control? You bet ya. This ridiculous critical value calling peeve is not one of them. Just another disconnect where many might assume, you know, because this is a professional job and all, that one could make those kind of calls without risking discipline or even job loss based on the whimsy of a toxic facility or manager. This is yet another one of those daily issues that are mandated by strict protocol and policy that become malleable through accepted practice by necessity(thankfully), that is until the 'failure to follow procedure' rap might handily come into play somwhere down the line.

And don't even get me started with suggestions for plan when making some phone calls....what, you went to medical school, blah, blah. Sheesh..another can't win for losing..

Again, we got our own problems but this one is on the facility.

[Cindy-san]

Do you know how many times I have done mitered corners since nursing school? ZERO.

I don't even tuck the top sheet in anymore. Easy access to the feet.

Regarding the doing first and getting orders later thing, most people at my job "do" in an emergency, but in a non-emergency....

Some people at my job don't even bother to send labs to recheck lytes if the doc doesn't order it. Even when the pt's on CRRT. In a way I understand, people have gotten yelled at for doing conflicting things, especially when one doc tells you to do something, doesn't order it and some other doc is unhappy about this being done.

"They don't order it, I don't do it" has become a big mentality on my unit. Which is terrible IMO, b/c it ignores an important part of assessment and critical thinking. I stopped "asking" for orders a long time ago, and started "telling." I find that and a call to a higher-up if there's an issue, works nicely.

[hypocaffeinemia, BSN, RN]

I don't even tuck the top sheet in anymore. Easy access to the feet.

Regarding the doing first and getting orders later thing, most people at my job "do" in an emergency, but in a non-emergency....

Some people at my job don't even bother to send labs to recheck lytes if the doc doesn't order it. Even when the pt's on CRRT. In a way I understand, people have gotten yelled at for doing conflicting things, especially when one doc tells you to do something, doesn't order it and some other doc is unhappy about this being done.

"They don't order it, I don't do it" has become a big mentality on my unit. Which is terrible IMO, b/c it ignores an important part of assessment and critical thinking. I stopped "asking" for orders a long time ago, and started "telling." I find that and a call to a higher-up if there's an issue, works nicely.

The problem is that, especially in ICU, we're in a catch-22. Intervention needs to be done without delay, but if anyone actually made a stink about it, your license could be in jeopardy. At least in the ER, you can grab a quick verbal and everything's kosher, but at this community hospital ICU, without interns and residents, the ICU nurses have to act decisively before there's even time to page the attending, let alone waiting for the callback. Somebody's seizing, you grab some lorazepam, give it, and then call. Technically, it's practicing medicine without a license, but it's what needed to be done. It'd be nice to have a 24/7 NP/PA in-unit to cover butts for emergencies and stupidly routine stuff. Why call some poor asleep dude at 4 AM for a stool softener or a quote-unquote "critical" lab when you can just bounce that stuff off the intensivist PA/NP (glorified permanent intern)?