What Happened To The Nursing Profession?

hypocaffeinemia, BSN, RN · Mar 25, 2009

I'm a pre-nursing student, just finishing up my A&P2 lab this semester. It's been 5 years since I took A&P1 and A&P2 lecture. Of course I've forgotten everything I learned back then in A&P. I'm doing good in the lab, but it's all just memorizing the locations and labeling of things, not the way things work (I would have gotten that in the lecture 5 years ago). I've been concerned that no being "fresh" on this stuff will hurt me in the nursing program and as a nurse. But I've heard others (on allnurses) say that you don't really have to know much A&P to be a good nurse or get through the program successfully. I don't just want to pass through though, I actually want to be good at it. But I also don't want to take a whole class over again that I already passed with an A. What do you think I should do?

Grab your A&P text and study the heck out of it.

Patients deserve better than someone who's understanding of, say, beta-blockers is that they are "BP medications", in my opinion.

GilaRRT · Mar 25, 2009

A rather sad state of affairs IMHO. The problem is multifactorial; however, the buck stops at education. We are simply cranking out sub-par providers. Many factors such as lack of qualified instructors, high student:instructor ratios, larger classes, limited funding, "fast track" programs, and significantly less emphasis on disease process, EBM, and clinical practice are among the many problems.

We need to face the fact that some places are simply cranking out "skill monkeys" who react to a number without any real idea of what is going on with the patient.

FireStarterRN, BSN, RN · Mar 25, 2009

I really think a big part of the problem is simply 'warm body syndrome'. Lack of comprehensive precepting, rush to fill hard to fill shifts, and unwillingness to confront or monitor competency. Instead managers are busy making sure rounding sheets are filled out, fall precaution sheets are complete, and every other multitude of exacting regulations are met.

Now, systems are blamed for individual failures. One nurse screws up, so then everyone has to do another ritualistic double check which is a one sized fits all solution offered up by ivory tower paper pushers.

So, individual accountability has given way to system failures. And common sense has gone out the window.

Virgo_RN, BSN, RN · Mar 25, 2009

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.

This. I am quite capable of critical thinking, and often know what the right course is, but I need a doctor's order to cover my behind. I call doctors for things that I *know* are common sense, but it's not because I need the doctor to tell me what to do, it's because I need to be able to write that doctor's order so I don't get thrown under the bus for making a decision.

Though I do wonder at times if maybe there is a lack of critical thinking ability at play as well. Recently I was floated to another floor, and had a patient situation that I thought through and tried a couple of things before I bothered the doctor. When I spoke to the charge nurse and explained my thinking, she actually hugged me and thanked me for being able to think. I ended up having to call the doctor anyway, because my interventions didn't work, but the point is that I thought it through and tried some things before calling the doctor, and the charge nurse seemed genuinely impressed that I did that. To me, it seems like basic nursing, so I didn't get what the fuss was about.

This is why I love protocol order sets. Protocols give me the freedom to use my critical thinking and decide on a course of action without having to call the dang doctor for something that should be within my scope as a thinking nurse.

RN1982 · Mar 25, 2009

I love protocol orders. We have them for insulin, electrolytes (mag, phos and KCL). All patients have them ordered on admission. It's great so we don't have to call the doc if the patient needs a KCL supplement or 1/2 amp of D50 for a blood glucose of 50.

rngolfer53 · Mar 25, 2009

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.

Nursing is by no means the only profession with a lack of thinking. (I confess to the old-fashioned belief that all thinking is critical, else why do it?)

Sad to say, but many people stop learning after leaving school for the last time. Yes, there are typically CEs required for keeping one's license, but that is only a pittance, and many cram in their quota at the deadline for renewing. Like you say, you have to regularly read journals,etc. to improve your knowledge base, and thus your practice.

If you don't really like to stay abreast of current trends, etc, perhaps it's time to look at a new area of nursing, or a new job entirely.

Scrubby · Mar 25, 2009

I too agree with some of the doctors comments.

From my experience some nurses are what I call 'cruisers'. They come in to work, expect to be told what to do all day, don't think outside the square, always do the bare minimum and go home. They are useless in emergencies, they cannot function in a leadership role because they can't problem solve, but that's ok because the other nurse who does use critical thinking skills will come along and solve all the problems.....again.

Today I had a newer nurse with 6 months OR experience. I asked her if the patient has uncontrolled bleeding and it's getting messy, as a circulator what can you do to help out? She looked completely blank and said it's not up to her to stop the bleeding. I really hope I never have her as my scout nurse in an emergency.

And I'm not just talking about new nurses either. I've had "experienced" nurses as the circulating nurse and not only do I have to be the scrub nurse and hand instruments, but I have to constantly tell them what to do, I have to think for them as the circulator as well because they are incapable of thinking ahead, using any initiative and quite frankly I'd prefer they choose another area to work in. I usually just scrub them anyway because they are only good for handing instruments.

Anyway that's my rant, glad to get it off my chest and it'll start all over again tomorrow......

RN1982 · Mar 25, 2009

Sometimes experience means nothing. I've worked with people who are "experienced" in critical care yet flip out when something goes wrong, can't handle the situation and leave the room and let others take over.

edmurse77 · Mar 25, 2009

I like it aaaalot! This is a great discussion. We have spoken about this many times at work. #1) Why is everything anonymous - agh - anonymity lacks accountability and honesty. #2) Why do we make up new rules and more paper trails to cover up incompetence. ie:we co-sign pre mixed KCL solutions. #3) When an error is found "a nurse did it". ("WHO")

WalkieTalkie, RN · Mar 25, 2009

Speaking on what happened to the nursing profession... I got a patient from the cath lab a couple nights ago (our CPCU doesn't pull sheaths on nights). Anyway, his morbidly obese, wheelchair bound wife, whom I had to push into the room at 0300, yells "Nurse! Can you get me a number for those people?"... as I'm clearly in the middle of something else in my other patient's room.

I had no idea who she was talking about. I actually thought she was referring to his doctor or medical team. Keep in mind I had already been in the room, introduced myself as his RN, and told her what they had done in the cath lab, explained how to use the call light, etc. She then said "Well I need to get ahold of those people!" and got mad at me. I asked her if she needed something for the patient, and she said, "I need to know how to get ahold of the nurse, to call up here today!" I was totally dumbfounded. I am one of "those people" and I have been talking to you the whole time! Who did you think I was?!

I've been called a number number of names in my time, but this is a new one. Did she honestly not have a clue that I was a nurse? Ugh!