When There’s a Disconnect Between Good Nursing Practice and Reality

Recently I spoke with other nurses about our personal experiences with hospitalization and those of family members, and the conversation turned to disappointment with nursing practice and nursing care. In fact, whenever I’ve asked, every colleague has disclosed a similar experience. Some say that they’d never leave a family member alone in a hospital.

We need to acknowledge that there is a disconnect between what we know to be good practice and what is often the reality—even in facilities with Magnet accreditation. There are far too many instances in which nursing practice is substandard.

shawnkennedyThis is a heads-up about Shawn Kennedy’s editorial in this month’s issue of AJN, excerpted above. You should read it. The article, “Straight Talk About Nursing,” is free. There are no easy answers to the issues it raises. That’s all the more reason to discuss them openly.

In AJN, we often focus on examples of best practices and insightful, compassionate, engaged care. And we get that there are many institutional obstacles that undermine nurses in their attempts to provide quality care to patients. But even so, we’d be remiss to pretend we don’t hear about, and sometimes personally experience, care that simply falls short. This is scary, at least to me. Patients depend on nurses in so many ways. So have a look at the article and let us know your thoughts, as a nurse or as a patient.—Jacob Molyneux, senior editor

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Senior editor/social media strategy, American Journal of Nursing, and editor of AJN Off the Charts.


  1. mmcs1998 December 9, 2013 at 9:09 am

    I agree that we are own worst enemies & rather than look at what we can improve upon we wait until it is forced upon us. Our wants if paper reading, eating, socializing, etc definitely needs to be secondary to patient needs. We need to ensure that our working hours are for the patient first.

  2. Shawn Kennedy December 9, 2013 at 8:09 am

    Yes there are issues and problems, but as I noted in the editorial, there are a lot of factors that are at play, so many that this seems a system and organizational issue. So what’s the solution? Is it more staffing, so nurses have time to, well, nurse?

  3. Susan Dameron Cote-Eagle December 7, 2013 at 10:17 pm

    Great article – would be nice if this got read by everyone that needed to read it.

  4. Joanne Wynn December 7, 2013 at 4:12 pm

    Many nursing programs do not provide enough clinical experience for the new grads to “hit the ground running”. My own daughter, who is a great nurse, was thrown into a situation in her first job with little clinical experience and little to no preceptor help. They just expected her to already have skills she had not been taught in nursing school except in a book. Luckily for her she changed units and had wonderful older nurses who were excellent teachers and a strong manager who saw her potential. She has been nominated for a Daisy twice in her first year on this unit. New nurses need lots of clinical experience when they are in nursing school. When you get in the real world without these skills under your belt, you can only be as good as the preceptor you get. We need to go back to the old way of teaching with “hands on care”.

  5. Nan Scott December 7, 2013 at 1:39 pm

    Compassion in nursing is one of the most important principles if not the most important principle in nursing. One must have it and nursing programs need to identify what this is and how it can be nurtured and fostered. While I was saddened to read this, I too have said, “If I go to the hospital don’t leave me alone.” Nor would I leave a family member alone. I have 40 years in nursing and remember when nursing was a “calling.” Now, we encourage high school students to consider nursing “because you’ll always have a job.” I went to screen a patient in the ICU for admission to a Skilled Nursing Facility (SNF) and found the nurse at 11:30 am reading the paper at the nurses station, eating fast food and not in the least disturbed that I had shown up. The patient was sitting by her bed, morning breakfast remains on her face and gown, her hair not combed, her oxygen tubing half out her nose, and no slippers or socks on and her call light out of reach. When I saw her she asked to go to the bathroom. The census in this ICU was one patient. Nurses themselves have to appreciate that clinical practice is changing and will continue to do so. As a profession we need to recognize that advanced clinical skills and compassionate care are not mutually exclusive; high tech does not have to mean low care.

  6. Tobey December 7, 2013 at 12:06 pm

    As a newer graduate my opinion is that all the “book learning” is necessary and informative but it does not prepare you for working on a floor with real life situations. We went to a variety of clinical sites. Many times we were viewed as a nuisance or in the way. We ended up doing a lot of bed baths, changing and feeding people. The students in my class were excited and proud to become nurses but I realize now we were woefully unprepared for the situations we would encounter. I was fortunate to have been a CNA for 13 yrs and worked in acute care, rehab, LTC, but the students who were experiencing the world of nursing for the first time were even more overwhelmed than I with the number of patients and amount of responsibilty given to us on our first jobs. We were not qualified to handle many of them. A clinical class with 8 students and one instructor in which one student gets the opportunity to give a heparin injection while the others watch just doesn’t cut it.

  7. mmcs1998 December 7, 2013 at 10:34 am

    I believed that we are responsible for quality care by using the principles of our profession that we were taught and licensced by. It is up to each of us to not compromise and ensure there is quality care. Somehow the purpose of what the profession is all about gets lost in pettiness, bickering, challenging etc. To stand up for what we can do under our license and what we should not do is most important. I personally would rather be fired than to compromise and put a patient’s care in jeopardy. I personally believe we sometimes need to look at what we should be doing and delegating off what is not ours to do. Also discipline and focus at the workplace brings a lot of time that I never knew I had.

  8. mmcs1998 December 7, 2013 at 10:30 am

    There is nothing that should undermine good nursing care if we practice the principles of what we are taught. It is up to each one of us not to shortcut and/or eliminate practices that are part of our profession. More of us should stand up for what we can capably perform with the quality and practices that provide optimum care. This might mean that we move a bit faster and/or eliminate those duties that can be done by a nonprofessional but we must live up to what we have been taught and licensced to do. I would rather be fired from a job than to provide less than quality and professional care. I am the one that will have to live with it.

  9. Katie.benn@allegiance.heLth December 6, 2013 at 8:22 pm

    Cell phones need to be BANNED for staff that provides patient care!

  10. Suzanne Pedjoe December 6, 2013 at 6:29 pm

    The problem is nursing’s over reliance on technology. After spending 4 days hooked up to telemetry for uncontrolled htn and cp not one nurse verified a pca taken bp before giving me several doses of ivp lopressor and nobody ever checked an ap with a stethoscope. I’m not sure nurses even are required to have one anymore. What happened to a good old fashioned physical hands on asseement that took place when heaven forbid you bathed your patient?

  11. t abell December 6, 2013 at 3:51 pm

    After reading these stories, I am now scared to death!

  12. Oletimer December 6, 2013 at 2:30 pm

    The CEO of our hospital went through our unit the other day and came back later to inform our director that no one ever even looked up at him when he walked through. Every staff person was surfing the internet and/or their cell phone. And this is in a CVICU.

  13. Mary W. Studious December 6, 2013 at 2:12 pm

    I am a graduate student intending to teach nursing in a little over one year. I love the profession, but I see the negative side of it over and over. From my own perspective, after I had a knee replacement, a cheerful nurse came in and stood by the doorway and said, “I have your insulin”. I do not take insulin. When I told her that, she spun around and ran out. Never an apology or any remark that could tame the horror building in my brain.

  14. Amani December 6, 2013 at 1:06 pm

    I hope this article goes viral and all Nurses give it a good read. Thank you for sharing it!

    I am a Nurse who did bedside for 5 years, left to teach abroad, and now I’m in a corporate setting. Despite the trend, I absolutely miss bedside Nursing and patient care. I’ve met with friends who are working in the hospital setting though, and not one of them has urged me to come back out of love for the job. All I hear are horror stories of inadequate staffing, bullying amongst colleagues (that’s a big one!), and all of the other examples highlighted in the article as to the “many reasons [that] may underlie omissions of care…”

    I’ve been told the grass is greener b/c I’ve stepped away from the bedside,and I only remember the good parts of Nursing. It’s an absolute shame that the positive doesnt outweigh the negative. Nurses (at least the the ones I know working in major medical centers that are constantly busy) are not going into work happy and hopeful. This mood alone will affect the quality of care.

    “We also need to look at how nurses are being taught to provide care—are we missing something? ” Yes! From my perspective, not enough emphasis (not even in Nursing School) is placed on being a quality bedside Nurse and emphasizing pride in such a wonderful career. Over the years, the push has been for Nurses to achieve a level of education that will allow them to “move away from the bedside” implying that the bedside is a low-class position. If great Nurses leave the bedside, then yes – inexperienced new grads on constant turnover without the critical thinking experience will be left in the hospital to take care of your mother.

    We need self established pride in our profession.

  15. Becky Lehr, LPN December 6, 2013 at 12:38 pm

    I also have my own tales from the other side of the bed-rails. Hospitalized with recurrent diarrhea and unable to tolerate the oral antibiotic I spent 5 days in the hospital I worked in. Since my admitting doctor was a surgeon he had me placed on the surgical floor (yikes). After endoscopy I was diagnosed with antibiotic induced C-Diff. Knowing that I should have been placed in isolation I mentioned this to the nurse and was told that the supplies were outside the door but no one flet they needed to use it because they knew me (WHAT???). Yes, I was still on the surgical floor!

    The admitting doctort also assumed I had been several days without food or liquids (I came in after 30 minutes of such severe nausea I couldn’t stand for the lightest clothing to touch my stomach) so set my IV rate at 250. This did not change until two days before I went home. Accurate I & O was kept, however the nurses never paid attention to the totals & I was filling up with fluid. I finally pestered my PCP into giving me HCTZ and put out more in the next 8 hours than I had in the previous 24.

    I also had a food allergy that I had forgotten to list on my admit questionaire but later told the nursing staff about. It was never placed on my chart, even after a friend who worked in the kitchen questioned whether I should receive it.

    I later used my own chart to teach a nursing class on the importance of accurate documentation.

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