1. Blake, Janet MSN, RN, CNM, CSN


A nurse perceives a possible decline in her own cognitive abilities.


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For my last few years as a nurse, I wondered if I was mentally competent enough to remain in clinical practice. I had enjoyed a rewarding career for 47 years and loved past roles as staff nurse, nurse-midwife, nurse manager, and clinical instructor. But I'd grown concerned about recent deficits-short-term memory loss, diminished word recall, and difficulties with multitasking. My judgment and nursing knowledge remained intact, and for a while I tried to ignore these issues. Then I attempted to compensate for my memory problems by writing down all details. But this did not improve my organizational skills nor time management.


So, I consulted a neuropsychologist for a cognitive evaluation, and underwent a battery of tests. We measured functions such as attention, concentration, short-term memory, verbal memory, and executive function (problem-solving). Results were given as percentiles for my age group. Some were considered average. Others were below average.


At this point, I was working as a staff nurse for a home care agency. I felt certain that I would be safe following a care plan for a single pediatric client in a home setting. But even in this setting, I would doubt myself. I began asking myself, "Did I mix the G-tube formula correctly?" "Did I set the pump rate accurately?" "What were those correct settings for the CPAP?" I didn't trust my own memory or notes.


My professional self-image had been one of competence and thoroughness. For years, I had been a role model for nurses and students I had mentored or taught. These changes were difficult to accept. I finally decided that it was time "to hang up my stethoscope." Many journal articles about how to retain older nurses in the workplace have focused on the challenges of learning new technology, hearing loss, or preparing for retirement. Some articles suggest that mature nurses could find satisfaction in mentoring novice nurses or reviewing charts. But the authors of these articles assume that the mature clinicians still have competent judgment and a solid base of knowledge.


Among its standards of professional performance, the American Nurses Association (ANA) includes professional practice evaluation, which stipulates that the nurse "evaluates her or his own nursing practice in relation to professional practice standards." But I have not read anything that specifically addresses the issue of nurses recognizing and admitting incompetence in clinical nursing practice.


By contrast, the question of whether and how to regulate the aging physician's competence has received increasing attention in recent years, with a number of sources reporting that some hospitals have implemented mandatory or voluntary tests of competence for physicians above a certain age. In 2015, the American Medical Association (AMA) voted to develop guidelines for assessing the competency of older physicians. However, concerns about ageism and discrimination remain. According to Shannon Firth writing for MedPage Today (November 2018), the guiding principles for assessing competence developed by an AMA committee failed to win approval from delegates at a 2018 interim meeting. At least a major professional body for physicians is examining this patient safety issue.


I suspect that I am not alone in dealing with this dilemma. Cognitive decline and the resulting insecurity and/or incompetence is a sensitive issue for a professional nurse. It can cause anxiety and depression. How can we address this issue without opening the door to ageism or other forms of discrimination? We need to explore ways to offer nonjudgmental assistance to colleagues struggling with the question of whether it's time to leave nursing. Perhaps a task force could explore strategies such as peer review or utilizing a nurse who is experienced in staff development as an observer. Perhaps a reliable self-evaluation tool could be developed. Should we be tested at a certain age in order to remain licensed? Certainly, the present options of completing written CEU courses and tests or attending conferences are insufficient for identifying nurses with cognitive problems. I imagine that some nurses remain certified in their specialties but no longer perform safely.


This is a difficult question. I certainly do not have the answer. But as our nursing population ages, we must be willing to confront this important issue.