Whatever Happened To Nursing Care and Communication?

When I completed my training and joined the staff of our local community hospital to practice General Internal Medicine, every floor was run by a charge nurse. I had learned in medical school and during residency that if you wanted to get things done in a timely manner and get nights sleep while on call, you learned the rules and regulations on Mr. or Mrs. Jones floor and followed them.

In the late 1970’s and early 1980’s when you arrived to make patient rounds, the floor nurse would gather the medication list, the patient vital signs and go with you to the bedside. You would greet the patient, take a brief history, perform an exam and discuss the problems of the previous night with the patient and the nurse. You would receive a direct verbal report from the day shift nurse or departing night shift nurse of the patient’s concerns and the nursing staffs’ insights, thoughts and concerns. By the time you moved on to the next patient you had answered all questions, reviewed all medications, discussed the plans and goals for the day and reviewed the lines of communication .  These nurses had graduated high school and gone on to a two year nursing school. They received on the job training and supervision from senior staff who had been working at that hospital on that floor for decades. These nurses could change a sheet and bedding on a patient immobilized in bed in traction. They took vital signs by holding the patient’s hand and looking into the patient’s eyes and feeling if the pulse was healthy and brisk and if the hand temperature was warm and dry. The therapeutic nature of the hand holding and human touch was grossly underestimated by administrators and economists

In the mid nineteen eighties, as health insurance companies began to rule the care of patients at a discounted rate, things changed. At the local corporate hospital nurses stopped coming to the bedside. In fact they stopped getting a direct verbal report from the outgoing nursing shift.  The outgoing shift left their report on tape recorders for the incoming shift to listen to when they had a chance. Gone was the stability of tenured and experienced nurses replaced by per diem nurses from temporary agencies who could be practicing in one hospital on Monday and four others the rest of the week.  These nurses might be seasonal employees flown in from Scandinavia or Canada to service the increased winter seasonal volume in South Florida. They were no longer great care givers. Most of them were now going from high school to four year colleges to study nursing. Many were then encouraged to go on and get graduate nursing degrees.  Nurses with a four year degree were not looking to empty bed pans, change bedding or even change bandages unless wound care was their designated specialty. Outside the critical care units, they were primarily administrative, directing “aides” with little or no formal school training and no nursing school training. BP cuffs were replaced at the bedside by robots. No longer were hands held to check vital signs. No longer did the nurse have time to go to the bedside with the doctor to review the patient’s progress and identify the problems and goals for the day.

They became so well educated that nursing couldn’t keep them in the profession. They wanted more. They became physician assistants and nurse practitioners so that with their advanced degrees they could be given more clinical responsibility and allowed more clinical decision making. The problem is that they were not given the formal training one need to have to make these decisions. They were not given the arduous clinical oversight of a large volume of cases one needs over a prolonged training period to become a trained clinician.  They were supposed to assist primary care doctors and generalists and expand the ability of our small primary care population to see patients. Unfortunately, these PA’s and NP’s soon realized that there was no money in primary care and most generalists could not afford to employ them anyway. It was much nicer to work for a plastic surgeon and orthopedist and do their entire pre op and post op care so they could stay in the OR and generate more revenue. It was much easier to leave the bedside and go work for hospital administration or a medical equipment manufacturer in sales then become a supervisor of under educated aides while filling out paper work all day long.

I miss the days of going to the bedside with the nurse and the medication sheets. We made fewer errors. The communication and rapport were better. The nurses were our eyes and ears watching and caring for our patients while we were in the office. The technology and training was supposed to improve communication not make it more difficult. I would love to see the two year nursing program for care givers return. We need doctors and nurses going back to the bedside. We need nurses who are allowed to care for patients rather than supervise others and fill out checklists.

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