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  #1  
Old 12-22-2007, 06:48 AM
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Default Nurses above the daily grind

Some nurses recently said to me that nursing has changed so much and we do so much more, that we might as well be doctors. The two nurses who said this to me were both nurse anesthetists. They then went on to say that there a so many unskilled jobs that anyone could do, and that nurses should not have to do. In particular, they were referring to jobs such as showering/bed sponging, feeding, and dressing wounds. I found this rather sad. It seems that the fundamentals of nursing are being forgotten.

Confused? Well I'm referring to the days when RN's took care of the whole patient. Meeting hygiene needs, dressing wounds, and feeding patients eg stroke patients are not for the unskilled.

To me this feels wrong? It's these tasks which keep us in touch with the patient. For example, when we wash a patient we assess so much. When we log roll them onto their side we check their pressure areas, feel their skin under our hands: Are they hot, dry, cold and clammy. When we move them do they cough, does their chest rattle. When we feed a stroke victim we assess their ability to swallow. This is rather important as aspirating food into the lungs is never good. When we dress a wound, we observe each day its progress, it's shape, size, colour, odor, discharge. Is it pale red or angry red? There is so much that an experienced nurse automatically assesses when they look after the basic needs of a patient and it is not for the unskilled.

I realize that we do so much more, in some cases diagnose, treat/prescribe, or maybe we're nurse anaesthetists, but I feel that the absolute basics should always be a part of nursing. I am happy to delegate some basic jobs, but it should never be delegated because we feel it is a simple unskilled job for the unskilled health worker.
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Old 12-22-2007, 06:24 PM
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I completely agree nursingaround. While it is great that as nurses we have so many skills these days we must not forget the basics of nursing care because actually that is what the patient will remember. If a nurse thinks they might as well be a doctor then one wonders why they didn't get themselves to medical school and become one!

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Old 12-22-2007, 09:43 PM
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This might also have something to do with under staffing nurses. As we get more patients we start to forget about the finer details to have to focus on all the patients.

Students in my course have seen nurse log roll a patient onto their side, the patient started to scream, the nurse response was 'I'm not touching your hip'. Where in fact the nurse had just rolled the patient onto the fractured hip.

The role of nursing is changing, but in a good way. But as you said the basic daily procedures are still required by the nurse. When people start to question these basic skills you have to wonder what the role of a nurse is and how we do our jobs. It might be better to think of us as the undercover spys of health! We are involved in our pt's care, but we are constantly assessing range of movement, stability, conscious state, skin integrity; and unlike a doctor we are constantly implementing these as subtle tests.

I have seen patients look surprised when a doctor comes charging into a room because of something the nurse has picked up from these subtle tests, and this is where nursing is changing. We are learning more about medicine and we have to keep up with the latest diseases and conditions to be able to treat our patients appropriately.
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Old 12-25-2007, 12:34 PM
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An interesting post, as it explores the shifting nature of specialised nursing and identifies the bloody great whole it's going to leave behind.

My analytical/paranoid belief is that, in the shortage of medical staff and abundance (by comparison of numbers) of nurses, the health care system would/could work much efficiently if nurses were given more autonomy and less time/resources were wasted getting doctors to do things that do not require a full 7+ years of generalised medical training.

I have long awaited/promoted the nurse specialist/advanced practitioner role and believe there is a place for such a person in today's and tomorrow's health care.

Of course, one could argue that Enrolled Nurses [EN] (UK & Oz), which I believe is equivalent to LPN (in USA), can upskill/backfill easily to the RN positions.

However, I do fear that those who 'back fill' their nursing duties will not be required to have a basic concept of nursing (ie health care assistants, care support workers, etc) and thus all we will do is shift the time/resource loss back down the chain of events to the direct patient care-givers.

Until of course someone identifies we have an acute lack of people able to do the basic things and we start encouraging unqualifed staff to take specialist training in specific tasks, like we have encouraged RN's to undertake specialist training to supplement (former) medical duties and EN's to undertake specialist training to carry out RN duties.

In reality this means not 'upskilling' anyone at all but downgrading and streamlining the training and titles and I would suggest the future looks like:
Unqualified staff already assist in areas EN's used to and, with specific competence training, will increase to all EN/LPN duties, including some who can administer medication or change dressings under supervision of an EN.
EN does 18 months/two years competence training and does further 18 months practical and becomes an RN equivalent
RN does 3 yrs training and advanced specialist skills/experience and becomes a specialist registrar equivalent
Medic - who knows, after 2 years on the job might become consultant?

Of course, after several years (?generations) of unqualifed staff doing the EN duties, someone will identify that they no longer have the time/resources to make beds, empty pans, assist each other in basic tasks, etc; and we'll introduce the new role of the "care support worker's support worker", or for USA, the "Health Care Assistant's Assistant".

It's a kind of subtle and quiet boundary shift - that I'm not all that worried about other than ensuring that, once RN's become advanced/specialist workers; what support and training are those that backfill going to have?

In my psych field a lot of nurses are now performing in areas that cross boundaries with psychologists, psychiatrists, social workers and OT's and at a consultancy type level. For years CPN (community psych nurses) and experienced ward based psych nurses have more or less been prescribing (they just go thru the formality of asking a consultant/registrar to sign up their recommendations).

No one is really moving the professional roles up, I think they're just moving the task/skill pre-requisites down to allow other grades and professions to administer them. Is this bad? I'm not convinced yet but by the time it's all finished, nurses will be equivalent to doctors, I'm sure....

...and then we'll be posting on nursingmedicsvoices.com, spouting about how "junior nurses" just don't do as we tell them because they're claiming they are not 'nursingmedics' hand-maidens anymore....
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Old 12-26-2007, 03:16 PM
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Wow - very interesting conversation.

No matter what title you hold, you cannot get away from actually performing patient care; it is what we do.

Doctors may be able to see a patient for fifteen minutes and draw up a medical plan, but every time we look at a patient, touch a patient or help them with ADLs we are learning about the patient. You want to hear about the urine output, or do you know more because you SAW it?

I actually lost a point in a class last semester because I did not agree with the instructor that more technology was better with regards to patient care.

Primary nursing, with one nurse and 3-4 patients is the way to go, in my opinion. These were the times that I was in touch with my patients every move, every change.

I think nursing can grow without taking the "nursing" out of the nurse"...

Blog post coming on!
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  #6  
Old 12-28-2007, 07:25 AM
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I can't entirely agree Kim, tho nursing should always remain nursing in it's philosophy, it has developed so much over the last few centuries that I can't shake the feeling that nursing will simply grow up another level and other nurses will stay at 'hands on' levels. In the last two generations, particularly where nursing has taken a greater responsibility for academic work in assessing and planning, and in some cases as discussed, in delivering specialised care, time spent with patients has reduced by the demands of other role responsibilities.

Also, look at todays specialist nursing positions: clinical roles of eg incontinence nurse, diabetes nurse, that have developed to provide consultation and liaison to the nurses who provide the hands on care. How is this different to a doctor who trains in urology or endocrinology? They do some hands on perhaps, but mostly teaching, policy development, care planning input and provide a link to expert practice guidance. In management we have nurse managers in varying roles. Our local 'business planning' co-ordinator is a nurse by profession. He has zero patient contact but his nursing knowledge is invaluable to successful and realistic business planning for the organisation.

We are creating positions that originate in clinical governance where nurses are tasked up to identify and mitigate problem areas such as Patient Safety Officer, Falls Prevention Officer. Much of these roles spend time in systems analysis, policy development and organisational reform etc. Nothing much about direct patient care there. Yet nurses doing these roles bring with them a wealth of knowledge and, most importantly, a philosophy of nursing.

So why is nurses becoming more clinically trained and responsible such a big difference to what we are already doing? Nurses today spend less time at the bedside than their Crimean War counterparts. They also knew a lot less about the science than their leading doctor, but the knowledge divide between nursing and medics is fast disappearing.
My clinical manager has title of Nurse Consultant and runs the nursing in my department; he knows and understands the holistic issues nurses face. He also has very little time to spend with patients but, where complex cases require, he will step in and support or direct care. He rarely has more than 15 minutes with each patient. Does that sound so different to a medic?

Ok, I'm in mental health care and we do things different anyhow but, personally, I feel better having to approach my "nurse" consultant than my medical one. At least they have a better appreciation of the nursing issues and not just focussed on moving someone thru diagnosis, treatment and discharge.

Nursing, for me, is so enjoyable (and preferable) because it looks at all aspects of person care and it also looks at all aspects of treatment. I would prefer my clinical direction to come from an experienced nursing background rather than a medical one that is tangential to nursing.
However, I do hold reservation that the move of nurses into more senior clinical roles will play out much like the Stanford Experiment did, where simply by their new found roles, Dr-Nurses take on a whole new persona and character that will leave them looking not a lot unlike a medical doctor.
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Old 12-28-2007, 02:19 PM
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Nursing, for me, is so enjoyable (and preferable) because it looks at all aspects of person care and it also looks at all aspects of treatment. I would prefer my clinical direction to come from an experienced nursing background rather than a medical one that is tangential to nursing.
Beautifully said! The trick is to grow and keep nursing's distinct character. I hope we never get sucked into the medical model. You gave some great examples of how nursing experience helps patients even when not at the bedside!
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Old 12-28-2007, 11:31 PM
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Default That's the trick....

There is so much discussion on moving nursing from a vocation to a "profession" (Man, I'm tired of school right now!) that I am always afraid we will start to move the "nursing" out of nursing...

The trick is to keep developing the role and responsibilities without changing the basic form
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Old 12-29-2007, 05:21 AM
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The key to this is for us to know exactly what the core values of nursing are but to accept that not everyone has to demonstrate those in the same way to call themselves a nurse. Someone who spends their career at the bedside, and who though they keep up to date chooses not to 'advance' and study for their masters or whatever is no less a nurse than one who does. At the same time you can advance, but you must keep one eye on where you came from and in practising as an advanced practitioner (or whatever your title says you are) you must not look down on those who work in a more routine role.

There are lots of nurses in the UK now who work in the roles that Ian speaks about, myself included. I use my nursing knowledge and skills every day, yet rarely trip over a nurse. It is as important for me to maintain those values of nursing as it is for my colleagues who work at the bedside.
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Old 12-29-2007, 07:14 AM
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Default Nurses doing nursing

I work night shift at an old age home "looking after" 30 frail and 30 semi-frail residents. The three staff members I have with me are called carers and have done a two week theory and two week practical course. We get stuck in together and do all the basic nursing care together. If they spot anything abmormal they have been trained to call the trained staff to assess the situation before they can continue. Yes I know its not a perfect system but it works fairly well.

We hardly ever see a doctor in the home because we the trained staff do all the assessing and tests and then phone the Doc and tell him/her what we want (antibiotic, night sedation, anti-hypertensive, laxitive). The doc then fax's the prescription to the local pharmacy and the medication is delivered later that day.

I feel nursing is definately advancing but to advance we must have a good understanding of the basics.

In the rural areas of South Africa nurses go on training to enable them to diagnose and prescribe so that the area is covered medically. They only need to refer further up the chain if their treatment is not working as planned. (Junior Doctors???)
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