I am aiming for this to be a provocative article. I want to start a conversation about where nursing has been, where we are now and where we are headed.
When I was completing my undergraduate degree and my graduate year in 2005, there was a push away from the task-oriented focus of ‘old style’ nursing. You know the type; I’m sure there are a couple of people reading this who still see remnants of that culture today. Patients must be up, out of bed, ready for breakfast by 0800hrs. Beds are to be made and all patients clean by 1000hrs. Care is dictated by the medical staff and carried out by the nurses.
This new age nursing was ‘patient-centred’. Individualised to the holistic needs of each person and dependent upon an understanding of what their priorities were. ‘Nursing is a 24-hour profession’ was the catch-cry of the early days of my career. The support was fantastic for a new nurse. I was told by many that it was more important to meet the needs of your patient than to get a bed made. A patient preferred to shower in the afternoon? No problem. The afternoon staff on the ward could do that.
The rules were changed. No longer could the matron walk past a room, scan for tidiness, cleanliness and order an evaluation of the skills and abilities of her nursing staff. The concept of scope of practice became the guiding principle for nurses to make decisions about not only what they could do, but to who, and what they could delegate to others.
During this time, our nursing profession has increased its skills, abilities and professionalism immensely. I would have it no other way. It is now an expectation (in the majority of workplaces) that a nurse will play an essential role in the creation of a patient’s plan of care. They no longer simply perform the tasks ordered by the doctor; they are professionals in their own right and will continue to evolve as the health dynamics of the community change.
I am excited about these changes. I would love to evolve myself. But then I read articles such as ‘Basic Nursing Care to Prevent Nonventilator Hospital-Aquired Pneumonia‘ from the Journal of Nursing Scholarship (2014). This was a US-based study that showed two main points: the first was that non-ventilated hospital acquired pneumonia (NV-HAP) was significantly underreported. The second was that a 12-month intervention period involving the implementation of an oral care initiative (nothing technical, just plain old mouth care) resulted in a reduction in the rate of NV-HAP by 37%; 8 lives potentially saved, 500 extra hospital days averted and a return on investment for the organisation of $1.6 million in avoided costs.
A paragraph from the article really made me think:
“Of the 115 NV-HAP cases reviewed, there was a lack of documentation of basic nursing care. In the 24-hours prior to the onset of NV-HAP, 84% did not receive coaching to cough and deep breathe each shift, 73% did not receive oral care each shift, 59% were not mobilised each shift, 34% did not have the head of the bed elevated each shift, and 28% were not documented to have good pain control.”
As a clinical nurse educator, I believe that we face similar issues in Australia. Have we quietly become so busy that the basics of our care are slipping?
This article is not intended to place blame on any nurse. I am a nurse. I know we do the best job we can with the resources available to us. I posed this question to a group of graduates at the hospital I work at. They told me that they are so busy learning the technical tasks related to caring for a patient population that is more acutely unwell than ever before and that there just isn’t the time to prioritise the basics.
So how does this change? Is this kind of basic nursing care still the domain of the acute ward nurse? If not, then whose is it?
I don’t have the answers, but I do have ideas. We need to understand the consequences of the care we provide as well as what is sacrificed because of time and/or money. We therefore need more research. We also need to communicate with our managers when we find that we don’t have the time or the resources to do our job. It is easy after a shocker of a shift to debrief with our colleagues and try hard to forget the feelings that we couldn’t give the care we wanted to before turning up to do it all again the next day, but the fact is that our patients are suffering for it. And not only the ones in the bed with NV-HAP, DVT, wound infections, or pressure injuries, but also the ones waiting on the lists to have their elective surgeries attended to.
If patients really are at the centre of what we do, we need to ensure we have the knowledge to advocate for them. It is only when we band together that we can be heard.