Issue link: https://nnumagazine.uberflip.com/i/447263
C A L I F O R N I A N U R S E M A Y 2 0 0 5 15 owns it, found Taché. Are the MAs clinically supervised by a reg- istered nurse? Are the MAs paired up with doctors? Are the MAs supervised by a licensed person at all? Do the MAs have a job description? Those who work in organizations where their duties are defined, or narrower, tend to stay within those boundaries, she says. "The ones where there's no job description, where no one is necessarily supervising the MAs, tend to do whatever needs to be done." F or Barigian, the flu shot fiasco was just the latest in a long string of problems she's observed over the years since Kaiser's decision in the mid-1990s to staff their medical offices with medical assistants instead of with enough licensed personnel. She and other RNs say they routinely observe medical assis- tants giving medical advice to patients over the telephone and incorrectly teaching patients how to care for themselves after a procedure. The Kaiser system somehow exploits even routine tasks for which medical assistants should be qualified. Medical assistants often take patients' blood pressures and gather other vital infor- mation in preparation for the doctor, but in various facilities, Kaiser has established, or has tried to establish, blood pressure clinics where patients come and get their blood pressures checked by a medical assistant, then go home without seeing any other medical professional. They tried this in Fresno, at Barigian's facil- ity. The medical assistants were supposed to follow a "protocol" of talking to the doctor if the pressure was not within a certain level, but the RNs still believed the arrangement required the MAs to independently assess and interpret blood pressure numbers. "I went to the manager and said, You can't expect an MA to know what to do," she says. "And they said, All they're doing is taking their blood pressure. The patients could do that them- selves at Longs [drugstore]. And I said, But we're not Longs, we're a health facility!" The RNs voice particular concern about medical assistants administering medication. Currently, medical assistants can give any drug to a patient as long as the medication and dose is checked by a licensed person first. If the drug needs to be injected, the MA can do so only if she's completed the training, and is authorized and supervised by a licensed doctor. The "service" also needs to be recorded in the patient's chart. In the real world, breakneck pace of Kaiser's family medicine practice, however, corners get cut. Winter and other RNs interviewed say they know the med- ications the medical assistants are required to give are not always pre-verified by the physicians, and the RNs aren't checking them either. "The pace is really, really fast, you're seeing patients every 15 minutes," says Winter. "The ability to have checks and bal- ances is going out the window." "Everyone's busy," adds Calvert. "They don't have time to stand around and look. The nurses know they don't bring every- thing to them." Many RNs also mentioned concerns about a drug that med- ical assistants often give called Albuterol, which is used to pre- vent and treat wheezing and other breathing problems caused by asthma, chronic bronchitis, and other lung diseases. The Albuterol is put into a machine that pushes air through it, and the medi- cine is inhaled through a mask for about 20 minutes. One side effect of the drug is that it makes the heart beat very quickly. While the law says medical assistants may give these breath- ing treatments if the treatment is routine for the patient, that rule is not followed, says Calvert. Medical assistants are administer- ing Albuterol to patients who have never taken it before. "When people come to the clinics, they're in breathing distress," she says. "Especially with children, they're often not real stable, they're fragile." The patients' reaction to the drug needs to be closely monitored, but it's not uncommon for the doctor to be gone an hour before coming back. In the meantime, only the med- ical assistant is accompanying the patient. "The MAs can't assess if the child is doing better, or doing worse," says Calvert. "She can't teach the patient or parents what the medication is for, or how the patient should respond. This is way beyond what they were trained to do." Situations like these get at the heart of the policy questions that Taché, the UCSF researcher, is posing. "This is a huge prob- lem that we're facing right now," she says. "Should MAs be car- rying out some of these more advanced functions? What are the patient safety issues? Who's going to be responsible?" She points out that medical assistants are also concerned about the demands placed on them to perform nursing functions and are underpaid and overworked. "They do want to help, so end up in situations where a lot is asked from them without the training," Taché says. "It's very stressful." Toni Winter, a travel RN with Kaiser in Santa Rosa, is one of many nurses who believe that medical assistants in Kaiser's medical offices are performing tasks beyond their duties and training—particularly when they administer drugs. In the course of reviewing charts, as she is doing here, she says she often finds errors in care and holes in documentation by medical assistants. "I'm always catch- ing this," says Winter. "Who's minding the store?"