Nurse Deskilling

This post over at AJN’s blog, Off the Charts, argued, essentially, that nurses aren’t pulling their weight when it comes to discharge planning:

Recently, as part of an ongoing collaborative initiative on supporting family caregivers with AARP (see the comprehensive, and free, AJN supplement called State of the Science: Professional Partners Supporting Family Caregivers), I listened to a group of family caregivers talk about what it’s like to care for sick parents and relatives at home.

[snip]

What they said they needed most to ready them for caregiving was what nurses used to do to prepare patients for discharge: teaching patients and family members about dressing changes, medications and diet, etc.; helping them arrange for follow-up like home health care; and making sure they had prescriptions and knew when to make a follow-up appointment (or, sometimes, just making the appointment and sending caregivers home with a day or two of medications).

How did we lose these things? How did it come to be that these discharge preparation activities became dispensable? What next might we give away because there’s no time? Is there a “line in the sand” that we won’t cross?

I know in my own practice and practice setting (charge nurse in a busy Toronto-area ED) the discharge piece is essential to completing the circle when providing patient care. We routinely make referrals to social work or home care, give out information and do health teaching about diet, scripts, dressing changes, signs and symptoms of infection, when the sutures need to come out, when to return, OTC medications (we’re permitted to do this in Ontario) and so on. It’s all well within our scope of practice, and indeed I would think it’s a professional expectation. It’s a chance to appropriately end the therapeutic relationship and, of course, there’s a liability issue attached to not prepping well for discharge.

But I know all is not well in other places. The questions posed by the post are good ones, and the answer, has to do more with the attempted (and ongoing) deskilling of nurses over the past few decades — the idea that hospital administrations essentially view nursing as task-driven and routinized; nursing roles in this model are severely circumscribed and reduced to a set list of tasks to increase productivity and lower costs for the hospitals. The predictable result: nurses who are emotionally and intellectually disinterested and disengaged in their practice. Sound familiar? I guess the larger question this begs is to what degree are nurses themselves (and, it must be said, self-described nursing leaders) complicit in the deterioration of our profession; indeed, it’s hard to imagine another profession that would undermine itself and give up valuable roles so cheerfully.

Or maybe we should just give up the pretence that nursing is a profession altogether?

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  1. #1 by Sean on Tuesday 21 December 2010 - 2054

    *deep breath*
    I had to pause before I answered this one. The problem is, it’s not just a ‘nursing’ problem. it doesn’t just rest on the shoulders of our professions leaders either. Since when did patient discharge have exclusivity to just the nursing staff?
    As for ‘time’ and responsibility, how are we to keep ‘doing what we used to do’ while ‘being on the cusp of life changing evidence base practice’. There are two worlds of thought there isn’t there?
    I doubt we ‘gave up’ any of the above, it was shuffled or laterally moved so that we could acquire other responsibility within the ‘circle’ of a patient’s stay. The continuum of care gets more complex daily, since when did we ‘give’ anything up??
    We spend entirely too much time on what is not working, pointing fingers about complacency and placing the blame on those who ARE getting it done.
    I get a lil defensive when those of us on the front lines are asked why we’re not accomplishing something ‘else’ instead of asking how can WE get the job done.

    *deep breath*

    End of rant.

  2. #2 by Vernon Dutton on Wednesday 22 December 2010 - 0704

    The comments Shawn Kennedy heard from the caregivers as mentioned on the AJN (Off the Charts) blog come at no surprise to me. I have personally witnessed the “deskilling of nurses over the past few decades” and know how little nurses are doing to prepare (teaching) patients for discharge.

    “How did we lose these things?” As you pointed out, nurses are “task-driven and routinized” due to the ridiculous patient loads. The most important skill a hospital nurse needs now is time management. For the majority of nurses, the never ending tasks, endless charting, endless non-nursing duties and medications for so many patients requires management of every min. just to do what is absolutely required. – New graduates come to work with a good idea of what a nurse is supposed to do and the hospitals reeducate them as to what nurses do. A hospitals expectation of a nurse is to take as many patients as you can with little or no support and manage the best you can to do the impossible – and nurses have no time for ANYTHING out of the ordinary (required duties) including the luxury of time for teaching or the endless other contributions nurses have been taught to make. Hospitals have redefined nursing and it involves very little nursing.

    Unfortunately teaching and discharge planing is one of many things nurses no longer do and new nurses quickly learn – you just don’t have time to do – which brings up another issue nurse utilization by hospitals has caused, Nurse Integrity. I would be willing to bet that teaching and discharge planing was checked off on most of the patient’s charts of the caregivers Shawn talked to.

    It is apparent that all the high ideals, expectations and the future of (hospital) nursing (which are welcomed) are being recommended and proposed by people who have no idea of what hospital nurses really do! – It will not happen. Nurses did not give up anything, we have been “deskilled” and dumbed down by our utilization.

    “Or maybe we should just give up the pretence that nursing is a profession altogether?” Can what hospital nurses do be called a profession by any stretch of the imagination? I sadly feel like I have watched the “Nursing Profession) slip away, replaced hospital workers.

    Vernon.

    .

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