That’s me in the pictures, nearly thirty years ago. The white dress, pin and cap, along with white hose, white slip, white shoes, white cardigan and a special pen comprised my daily work uniform. Caps and pins were different for each nursing school. The pens were used to write in paper charts, a different color for each eight hour shift.
My nursing professors drummed in Nursing 101 basic principles. We did not wear gloves unless handling a bedpan or other body fluids. We learned to draw blood, start IVs, pass nasogastric tubes, change the linens on an occupied bed, and give nightly back rubs, all without gloves. HIV/AIDS couldn’t be found in a textbook yet. Universal precautions didn’t exist. We learned to touch and care for our patients without a glove barrier, as this human touch was the only touch many patients experienced. To wear protection was to somehow give the impression that we found them repulsive. We washed our hands in the patient’s room before engaging in patient care, but washed afterwards in the hall, so the patient wouldn’t feel bad about us washing them off.
The center of focus was always on the patient. Conversation was tailored to the unique individual. We were never to talk about ourselves or our lives. It was about the patient, and as a professional nurse, we were to keep any personal anecdotes to ourselves, never shifting the focus from the patient or the patient’s family.
Shifts were eight hours: 7-3, 3-11, and 11-7. We wrote in charts with blue ink for the day shift, green ink for the evening shift, and red ink for the night shift. SOAP notes were easy to follow. Flow sheet charting was easy to interpret. Nursing care plans were well thought out using critical thinking skills and entered in the Kardex.
Medication orders were transcribed to the medication Kardex. We mixed IV medications and prepared solutions, poured medications in cups, and pushed our med carts down the hall. Intravenous fluids were titrated using math skills to determine the required drops per minute and adjusted with manual roller clamps.
Licensing was a long process. Board exams were in Atlantic City after the 4th of July in a large hall with 2000+ nurses taking the exam together. The exams (paper and pencil) were given over two days in four sessions. Results weren’t received until the first Friday after Labor Day.
Hospitals charged for care provided and insurance companies paid the bill.
The New Paradigm
In most hospitals, nurses all wear the same scrubs. Mine happen to be dark blue. No caps. ID badges include our full names. Vocera is the preferred communication tool. Electronic Health Records replaced paper charting. Medications and supplies are dispensed from Pyxis machines. Patient identification bracelets are bar coded. The bracelets are scanned along with supplies, lab orders, or medications used. (I feel like I work as a store checkout clerk.) IV solutions and medications are run on controller pumps. Nursing board exams are taken at testing facilities by appointment and can be passed after only 75 questions (out of 265) are answered. Charting is done via computer at the bedside (I’m uncomfortable staring at a computer screen instead of focusing on the patient). Care plans require no thought – just check a care set and click off the boxes.As a technology geek, I adapted to this new paradigm. It is the rest of nursing today that troubles me. Click To Tweet
Nursing in Today’s World
Patients are called customers, consumers or clients. Nurses and hospitals are a service-based industry similar to hotels. We compete for customers with other hospitals in our area. Ratings (HCAHPS) can be reviewed by patients online. Reimbursement amounts from insurance companies (the largest payer is CMS) are based on survey results (patients’ perceptions) and other quality factors. It doesn’t really matter how well you care for the patient. What matters is what the patient thinks about the nurse. The customer is not always right, but in the eyes of the HCAHPS, they always are. Click To Tweet
Although I understand the concepts of infection control and universal precautions, I object to washing my hands in front of the patient going in and out – every time. I wash going in, wash going out, touch nothing on the way to the next patient, but still have to wash going in, out, and repeat. There is no trust. If the patient didn’t see me wash it is assumed it didn’t happen. Consequently, my hands are raw and cracked.
Gloves are worn for everything, even when not encountering blood or body fluids. I feel guilty every time I don gloves outside of what I feel is warranted – the patient receives no human contact.
Shifts, now 13 hours, make for a long work day.
Nursing interactions with patients are scripted. Holding a nursing license and having RN on my ID tag is no longer enough to assure the patient that I am deemed competent to provide excellent care. We’re told to introduce ourselves to our patients, tell them about our education, certifications, and years of experience. We are also required to make a personal connections, talking again about ourselves in an effort to establish a relationship.
It is none of their business where I went to nursing school or where I received my bachelor’s degree. If the State of New Jersey is satisfied with my educational grades, competencies and nursing board exam score, then I am qualified to provide professional nursing care. Period.
I don’t feel comfortable talking about myself to the patient in a scripted fashion. In semi-private areas the patients hear us all say the same thing over and over. I wonder how that makes a patient more comfortable with our communication skills and nursing care. I don’t want to share anecdotes and make forced personal connections with patients. I’m a professional registered nurse. It’s about the patient, not me. If, over time, I feel comfortable sharing when a patient asks, and if I feel comfortable making a more personal connection, I will do so.
Nursing consistently ranks high in ethics, trust and honesty among professions, even before the new paradigm.
I do what I’m told in because I am a good employee and I love my job.
The grass isn’t greener anywhere else. The shift in how we deliver nursing care comes from far above our individual employers. If we want to stay in the game, we have to adapt to the new paradigm. For those having difficulty accepting change, I think it ultimately comes down to deciding whether you can (or are willing) to adapt or if now is the time to review your career choices.
Healthcare is a big business. Competition is fierce. If we don’t adapt and help our individual employers achieve competitive ratings they will lose money, lose patient populations, shut down, and we’ll be out with them.
We don’t have to like change, but we do have to accept it if we want to keep our jobs.
Ms. Lopez Gray, a nurse blogger I admire, wrote “As a nurse blogger, I’m in constant fear of getting fired or in trouble for what I say outside of work, stuff that has nothing to do with patient privacy.” ( Adventures of a Labor Nurse). Anonymous, the nurse blogger at Florence is Dead, writes “Anonymity is a must in order to protect my job (‘at-will-employment’).”
What I write applies to all nurses and all hospitals in the new paradigm, and no criticism of any individual or employer is meant. It's a new paradigm for nurses, and it may take some time for us old-school nurses to adjust. Click To Tweet