Issue link: https://nnumagazine.uberflip.com/i/447263
16 M A Y 2 0 0 5 C A L I F O R N I A N U R S E A s far as A. is concerned, you're damned if you do, and you're damned if you don't. Last year, A., a 24-year-old medical assistant who has worked at a Northern California Kaiser facility for five years and agreed to talk candidly as long as her full name was not used, was circulating in a room for a case, when the doctor announced he was ready for the local anesthesia. The local had not been drawn and put on the doctor's field yet, so A. was asked to do it. But it so happens that just the week before, a manager had told A. she was not allowed to handle locals, so A. said, "I couldn't, it was out of my [role]" and politely asked the nurse if she could do it herself. The nurse couldn't leave the head of the bed, so A. had to leave the room to find another nurse who wasn't busy to draw the local. Of course, all the nurses were extremely busy. She searched for a while before she eventually found someone to complete the task. In ret- rospect, A. is unsure whether she is even legally allowed to circulate during those pro- cedures. For A., every day is a struggle to balance what she knows she's not supposed to do, and what the doctors and nurses she works with are constantly asking her to do. "The doctor will tell you one thing, a nurse will tell you another thing," says A. "And if you know something is wrong, and the nurse is telling you to do it, and the manager is telling you to do it, what do you do?" Besides drawing local anesthesia, she says she's also been asked to scrub for the doctors, and to continue to circulate. She says she's asked to go outside her duties and training at least four times a week, and sometimes a couple times during the same day. It's gotten so bad that she's even developed a strategy for dealing with these situations: She won't outright say no, but instead ask if they can do it themselves, or offer to go find some- one who can. Frustrated by the conflicting orders, A. tried to research her job duties and what tasks medical assistants are legally allowed to do. She tried to track down a job description for herself, but could not find one. She asked for a job description eight months ago, but has yet to receive one. She looked on the Kaiser website and found that medical assistants in dermatology appear to be able to draw locals, but found nothing written for her department. She tried to research the medical literature, but found little guidance. During her 16-week training to become a medical assistant, A. says her classes never taught her what tasks fell beyond the proper role of medical assistants. "They did say if you don't feel comfortable doing something, to say, 'That's not in my [role],' but they didn't explain what that was." A. believes that Kaiser should establish formal policies and procedures for them. They should receive official training and pass competency tests, she says. Ryder, CNA's Kaiser division director, agrees. He says it is Kaiser's responsibility to establish clear policies and procedures regarding the tasks medical assis- tants perform, as well as clear lines of authority for their direc- tion under the professional guidance of a licensed practitioner. Not only does A. worry about eventually getting in trouble by taking on work outside her role, she worries about the safety and welfare of the patients. "If I'm doing something wrong, and I'm not licensed to do that, they may not get the best care or the care that they need." S omething's got to give, say Barigian, Winter, and the other Kaiser RNs. Outpatient facilities cannot continue to rely on medical assistants to help treat sicker and sicker patients and do more and more complex tasks without compromising patient safety and health. Taché, the UCSF researcher, believes the proper role of medical assistants will become a "hot" issue in coming years. She anticipates that there may be a push to reg- ulate medical assistants more closely, either by requiring all to be certified, or for states to actually license them, though the latter option is only viable if states are willing to finance such a system. Don Belasa, president of the American Association of Medical Assistants, also reports that employers are preferring or even insisting that medical assistants have formal education and credentials, and that they keep those credentials current through con- tinuing education or retesting. The QLs have lobbied upper management at Kaiser to stop using medical assistants outside their duties and training and submitted a position statement that calls for the same care standards whether the patient is in a hos- pital or in a Kaiser doctor's office. The statement also calls for better communication and coordination across all Kaiser facil- ities, and for RNs to reclaim their role as the "standard bearer" of care. Kaiser has met them with only a lukewarm response, so the QLs are now preparing their next move by organizing and gath- ering information about protocols, procedures, and job descrip- tions in six areas where they see the most flagrant violations of medical assistant duties. In the meantime, RNs are working to teach themselves and each other about what medical assistants can legally do or not do, and protesting when Kaiser has medical assistants work beyond their proper role. "Medical assistants do have a role," says Barigian. "They room patients, restock the rooms, answer the phones, but Kaiser is using them for the nursing part. The registered nurse must take over patient care. I think that's the most important thing that we're being blocked out of. We're told we're supposed to be the one in charge, but that's not the way it is." Lucia Hwang is editor of California Nurse. "Medical assistants do have a role," says Tammy Barigian (above)."They room patients, restock the rooms, answer the phones, but Kaiser is using them for the nursing part. The registered nurse must take over patient care. I think that's the most important thing that we're being blocked out of.We're told we're supposed to be the one in charge, but that's not the way it is."