National Nurses United

I t was another busy Saturday last fall at a Kaiser Permanente clinic in Oakhurst, about 45 miles north of Fresno. With the flu season kicking in and the entire coun- try short on vaccine, nearly 70 patients flocked to the clin- ic for flu and pneumonia shots. The clinic was short staffed that day, and the RN who would normally be supervising was busy in the back with a patient having a heart attack, so the medical assistant supervisor asked another med- ical assistant to help give flu shots. When the nurse returned a while later, she saw that the medical assistant was pulling her syringes out of the Pneumovax tub. Puzzled, she asked the MA if she realized she had been giv- ing injections out of the wrong tub. Turns out, the tub contained both flu and Pneumovax shots, and none of the syringes were labeled. "Wait a minute, you mixed these all together, so who got what?" asked the RN. To make matters worse, the medical staff did not know who had received what shots and when, since the patients that day were not formally registered. The staff had stamped label stickers for each patient, but planned to enter the information into the computer later. When the nurse walked in, the stickers were strewn all about the table. "That was a major faux pas," says Tammy Barigian, an extended rural RN who works at Kaiser Fresno in podiatry and the one to whom the Oakhurst RN complained. "These medical assistants are being told to administer medications when they aren't supposed to. Kaiser did a root cause analysis, but they could- n't figure out who got what. A few patients needed to be redone." Luckily, nobody was hurt or suffered a bad reaction, but to Barigian and other Kaiser RNs who have grown increasingly con- cerned in recent years about the role of medical assistants in its outpatient offices, it's only a matter of time. In recent years, Kaiser has been steadily reducing the pro- portion of RNs to other healthcare workers in outpatient settings. At the same time, the HMO giant is training medical assistants beyond their job descriptions and reorganizing work so that med- ical assistants are forced to perform work that is inappropriate and that falls within the RN scope of practice. "These developments are a classic illustration of deskilling that's characterized healthcare industry restructuring for decades," says Jim Ryder, CNA's Kaiser division director. "Making medical assistants perform work that is outside their role is detri- mental to patient care, and an attempt to de-professionalize the delivery of care." The RNs don't believe this structure is safe or sustainable. "We've gotten an increase in the acuity of patients and we're doing more procedures, more complex procedures," says Jean Remer, a charge RN who works in Kaiser Santa Teresa's nephrology department. "Kaiser's created a disaster waiting to happen." Barigian and Remer are just two of a group of Kaiser "Quality Liaisons," RNs whose purpose is to serve as "go-to" people for RNs to report systemic nursing practice problems. Among the QLs who work in the outpatient setting, Kaiser's use of medical assistants is one of their top concerns. Despite several attempts by California Nurse to get com- ment, Kaiser did not provide a spokesperson to respond to inquiries about the Oakhurst event or the RNs' concerns about tasks medical assistants are performing. The mix-up at the flu shot clinic is just one example of errors that result from Kaiser forcing medical assistants to assume duties that should be handled by a registered nurse, argue the QLs. Many of the RNs can immediately rattle off a long list of inappropriate tasks they've seen MAs take on: measuring and assessing blood pressures for a schedule of patients; administering a wide variety of oral, breathable, and injected medications; giving medical advice to patients in person or over the phone; communicating verbal orders; and removing stitches without consulting a doctor or nurse. The RNs wonder: Why would management let a medical assistant do something in an outpatient setting that would never be tolerated in a hospital setting? If unchecked, the situation will likely worsen in coming years as outpatient care grows. Already, the vast majority of medical care is provided in outpatient, or ambulatory, settings, and HMOS, as well as hospitals, keep shifting even more work to clinics or doc- tors offices. An ever-growing number of medical therapies, such as cancer treatments, are done on an outpatient basis, as are what Feature | Story ■ ■ ■ Under Pressure C A L I F O R N I A N U R S E M A Y 2 0 0 5 13 To reduce costs, Kaiser hires medical assistants for its offices and requires them to work beyond their training. At the same time, the HMO giant cuts RNs. Nurses say this setup is a disaster waiting to happen. By Lucia Hwang

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