Issue link: https://nnumagazine.uberflip.com/i/280201
In California, Minnesota, Michigan, as well as other states, hospi- tals and other healthcare policy organizations are lobbying for med- ical assistants, paramedics, emergency medical technicians (EMTs), and licensed vocational or practical nurses to take on expanded roles. For example, in a July 2013 white paper, the UC Davis Insti- tute for Population Health Improvement recommended that Cali- fornia launch pilot programs in which paramedics who received additional training get to assess whether patients need to be trans- ported to an emergency department or should be treated by the paramedic as needed; to essentially serve as home health RNs to fol- low up on patients who had been discharged from the hospital; and to provide care for patients with chronic conditions. In one "Challenges" section of the paper, the authors write that "patients may perceive there are tiers of care or lower levels of care being provided by the [community paramedic] if the patient is accus- tomed to receiving care from doctors or nurses." They're right to worry, because it's true; this program does create inferior levels of care. In Michigan last November, Sparrow Health System replaced all the registered nurses at its urgent care clinics with unlicensed med- ical assistants, though nurses warned that this move was bad for patients. "Patients who walk into an urgent care should be assessed by a highly trained RN who can detect serious problems that may go unnoticed to an untrained eye," said Jeff Breslin, RN and president of the nurses union at Sparrow. "Registered nurses have the skills and experience to tell immediately whether patients need more advanced care." At San Joaquin General Hospital in French Camp, Calif., nurses objected last year when the hospital wanted medical assistants in its ambulatory care clinics to provide services such as diabetic foot screens. Management expected medical assistants, who in California are not licensed nor even certified by any medical board or body, to fill out a sheet that asked them to answer questions such as, "Has there been a change in the foot since last evaluation?" and "Is there a foot ulcer now or history of foot ulcer?" and "Does the foot have an abnormal shape?" The nurses had also obtained a copy of a separate "skills academy" form that supposedly recorded which in a long list of "skills" the outpatient clinic assistant (medical assistant) had received training in. These "skills" ranged from the diabetic foot exam just mentioned to staple and suture removal and "anticipating needs" for patients who complained of chest or abdominal pain. The RNs believe that these evaluations constitute nursing assessment and should be performed by a registered nurse, not a medical assis- tant, and are currently working on correcting this problem. These are all examples of how care by registered nurses is being split into simpler tasks that can then be parceled out to unlicensed personnel to complete. What's missing in this new model of medical care is a fundamental appreciation of how registered nurses are not educated, trained, and experienced to only just perform medical tasks, but to contextualize and synthesize all the information they collect to provide an individualized assessment of any particular patient. Nurs- es use that assessment to make ongoing judgments or decisions about the best course of therapy or treatment for that patient. Healthcare corporations who are attempting to break down nursing care into its constituent parts fail to understand that the sum of the parts does not equal the whole—or perhaps they do know but do not care. For the sake of their patients and their own profession, registered nurses must fight to protect their scope of practice and force them to care. "Hospitals continue to shop around for a cheaper way of deliver- ing care to patients, but it doesn't work," said Karen Higgins, RN and a member of the NNU Council of Presidents. "They've tried it before. It's never worked, and it puts patients at risk. You need to have a good, educated, experienced registered nurse." Hospitals will be accelerating rollouts of dangerous electronic health records systems any rn who has experience with electronic health records systems (EHRs), whether they be electronic charting, electronic medication administration, pharmacy programs, or computerized physician order entry, knows that they do not sup- port or complement nursing care. It's obvious to RNs that there is lit- tle nursing value in being forced to stand in front of a screen and click a bunch of little check-off boxes or select from pages and pages of drop-down menus. Instead, EHRs exist to help the hospital make more money by max- imizing billing for every item or service the patient uses unless, like Kaiser, the hospital is paid a flat fee for treatment. In that case, the hos- pital may use EHRs to limit the amount of care provided. Under any business model, EHRs also maximize earnings by limiting healthcare providers' use of independent judgment in treatment options. Built into these electronic health records systems is what's called clinical decision support software, which is just a fancy name for software code that prompts the user to adopt whatever treatment plan the computer thinks is appropriate based on a fictitious, "aver- age" patient in its database. This is the software programming that, for example, limits the choices you can check off when you are trying to chart or makes a pop-up warning window appear on your screen that you have to override if you want to continue. If this sounds like the computer is taking over your independent nursing judgment and maybe ultimately your job, that's because it is. Electronic health records systems seek to routinize and standard- ize care. Not only is this cheaper, but it's simpler and easier and can be done by non-registered nurses in non-hospital settings. There's less variation, everyone gets the same thing, care is not individual- ized. Again, there's less and less independent judgment involved, which is exactly what registered nurses excel at: applying their knowledge and experience to make decisions in unexpected situa- tions. Human bodies are not inanimate widgets; they are complex 4 14 N A T I O N A L N U R S E W W W . N A T I O N A L N U R S E S U N I T E D . O R G J A N U A R Y | F E B R U A R Y 2 0 1 4 "HOSPITALS CONTINUE TO SHOP AROUND FOR A CHEAPER WAY OF DELIVERING CARE TO PATIENTS, BUT IT DOESN'T WORK. THEY'VE TRIED IT BEFORE. IT'S NEVER WORKED, AND IT PUTS PATIENTS AT RISK. YOU NEED TO HAVE A GOOD, EDUCATED, EXPERIENCED REGISTERED NURSE."