The future of nursing……..food for thought

by Paul Bond on 18 September, 2010

We’ve all heard for years that nurses are in short supply and that it will only get worse (older nurses retiring and the boomers coming into retirement age, etc.). We’ve been told (by many different sources) that nursing as a stable field of employment will be one of the best for years to come. While I agree (that nursing as both a profession AND a means of stable employment CAN be a great field), I have observed a few trends that are potentially disturbing (at least to me).

First, are we not working against ourselves as a profession by pushing for more ADN and crossover programs (many of which are for LPNs or paramedics to get their ADN), while at the same time advancing the idea that the BSN should be the entry level into the profession? On one hand, we are advocating for more nurses to be able to be put to work. But at the same time, we are putting more barriers up in front of those who may want to enter the profession. While I understand the typical ADN program has essentially turned into a 3 year program (with pre and co requisite courses being needed for entry into the programs now), but by suggesting the BSN is the bare minimum to be a licensed profession nurse puts this designation out of reach of many. The cost alone of a four year college education is becoming more and more prohibitive for many people, and there looks to be no end in sight for tuition costs being raised yearly. This, coupled with the ever shrinking amount of grant and/or scholarship monies available, will only continue to make it ever harder for people to enter the profession.

Second, the continuing “health care crisis” that is gripping this society. We continue to wrestle with reform of the system, how to best accomplish this reform, how to pay for care, who will receive care, etc. Hospitals (the largest employer of nurses by grouping) are being squeezed tighter almost daily by federal guidelines, private payers (i.e. insurance companies), HMOs, etc. to provide more care for less reimbursement, while being held to a higher standard of care. Nurses (who provide or coordinate MOST of this care) are the single largest “cost center” in a hospital. What better place to cut corners, save money, and increase revenue than to decrease the amount of registered nurses working at any one time and supplement them with patient care technicians, CNAs, and multiple other “assistants”? It’s been well documented that more RN’s working at any one time decreases the total number of days a patient spends in the hospital, and decreases the morbidity OF that stay (i.e. quicker turn over of the beds, better outcomes of the care, and less return visits to the hospital for the same problem within 30 days), and yet we (as a profession) allow these cuts to continue. Minimum staffing guidelines are not mandated in most states, and hospitals and their advocacy groups continue to fight them where they come up. Many hospitals nationwide have been on a “hiring freeze” within the nursing department and many new grads and well seasoned nurses are having a hard time finding a job. And yet, we’re in the middle of a nursing shortage??? How is this possible? How is it being lost in the conversation of health care reform? How is it being allowed to continue? And most importantly, why does the public either (1) not know about this, or (2) not CARE about it? I see the nursing profession as a whole (said the American Nurses Association — our largest voice) as the main culprit. We, as a profession, do not stress to the public (those who can best influence government) the importance of the RN in the care of the patient. We allow regulators and legislators to govern (or not) what staffing levels can be considered safe, and allow the use of unlicensed assistive personnel to increase, and allow hospitals to understaff, heap more responsibility upon us (with no increase in nurses), squeeze more productivity out of the nursing department (how many of you have heard your department is running at greater than 100% productivity???), and attempt to skirt the profession every time they can. I don’t blame hospitals or administrators for this. They are in business to make money and stay in business. Many administrators receive bonuses based on productivity, amount of profit, etc. They are effectively doing their jobs by trying to control the largest portion of the workforce in health care. It is WE, the workforce, who I blame. WE who do not stand up as a group and say we’ve had enough. We who do not advocate to the public we serve that we need more nurses at the bedside and not more UAPs. We do not tell the public that more nurses equals better, more appropriate care and fewer days in the hospital. Why? Who are we afraid of? After all, it IS the truth.

So what of the future of our profession? Throughout history, nurses have provided direct bedside care to the sick and injured. That has been our traditional role. It used to be, that if you wanted to provide bedside care, you HAD to become a nurse. But now, we have all this ancillary staff to “assist” us because we are so bogged down with other tasks. And while technology is pushed as a way to help us better deal with this, it is actually used against us by our employers to give us MORE to do. We may now be able to document electronically, but we also now have MORE to document, more to be responsible for, and more to do…………and less time to be with the patient. Case in point………..bed baths. Gone are the days when most nurses give bed baths. This “task” has been delegated to any number of assistive personnel. A bed bath is now thought of as being something a nurse does not do. And yet, a bed bath is a great way to be able to spend a little extra time with your patient! You can assess his/her entire body for skin integrity, talk about their disease process and have time to teach them about it, find out about their social support network and understand where they may need some assistance after discharge, and even perform teaching on ADLs to help them better cope after they leave the hospital. Is THIS beneath the skill level of a registered nurse? Aren’t all of those things actually part of what a nurse is SUPPOSED to do? And wouldn’t doing some of this teaching a little bit at a time, on a daily basis, make the discharge process that much more easy? Instead of spending time going over a patient’s discharge medications at discharge, you could probably have half of them taught and discussed with the patient prior to their date of discharge! There’s an adage we use in the ER that says discharge planning begins at triage. Those who follow this mantra use every opportunity to teach the patient about their condition and how to better deal with it after discharge. That way, when we DO discharge the patient, the teaching is more of a reinforcement of what has happened during the entire stay in the department. This makes the teaching process more of a continual one as opposed to only happening at the end. And before anyone asks, yes, I place many of my own splints, do crutch teaching, clean my patients when they need it, etc. on a regular basis (as do many of the nurses I work with). We have techs do help out also, and they do a great job. But we also teach THEM during these times what to look for, what to teach the patient, etc. so that it is a continuum of care and they are extensions of what we do.

My mother, who is currently in the hospital and has spent many a night in one over the years, has commented on just this thing…….that the nurses seem to do less patient interaction and she see more “helpers” who say they are nurses to the patients than she see actual nurses. We’ve all read the studies and seen the changes hospitals are making to help designate who is an actual nurse and who is in the nursing department, but not an RN. Are we not seeing and understanding what this actually means?? Or are we just not caring what it means? Quite frankly, it means nursing is being diluted into something it has not and never was meant to be! Nurses are advocates for their patients within the health care system, and are the educators for the system. Where did we lose track of this? We, the bedside caregivers, have allowed other, outside entities to tell us what our role is supposed to be. We are now the documenters of the care provided by everyone else, and the medicine givers, and the paper shufflers for a system that is so bogged down in documentation that it’s not even remotely funny!

In my podcast of January 6, 2010, I made reference to an article that talked about giving physicians “assistants” to help them document, coordinate labs and imaging tests, etc., and posed the question that “what if nurses had these assistants”? Well, here’s a thought……..instead of giving me a patient care assistant, why not give me a documentation assistant and let ME take care of my patients??? Why not hire nursing school students to help me document my care (and that of everyone else we are charged with documenting), answering the phone calls, coordinating the information needs of the ancillary staff, making the calls to lab, xray, dietary, etc. about my patient, and generally helping take the mountain of clerical skills a nurse is expected to perform off of my shoulders and let me do what a nurse is SUPPOSED to do………….be at the bedside caring for and teaching and assessing the patient. Is this were done, just how much more care could you give your patients? And just how much better would nursing students understand what is expected of them when they graduated? And how much better prepared to BE a nurse would they be? And maybe more importantly, how many more nurses would be willing to come back to the bedside because they could actually take care of patients again instead of pushing papers around to help document care, help the hospital get better reimbursement, and help the physician stay out of court? And just how many more actual NURSING positions could be made available to give this care (remember as I mentioned earlier, more RN’s on a unit equates to lower mortality and quicker turnover rates of beds………..thus saving even MORE money for the facility!).

So what of the future of nursing? We have an opportunity in front of us to reshape and reclaim the nursing profession. It us our responsibility to advocate for ourselves in this age of health care reform. Will we seize this chance to take back our profession, or will we continue to allow outside forces to control our destiny? It’s up to us.

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