Increased use of unlicensed staff raises red flags for nurses, Congress
Supervise UAPs in several ORs? No way!’
Picture this scenario: In Room 1, a patient is undergoing a septorhinoplasty and has severe cardiac changes following the administration of topical cocaine intranasally.
In Room 2, an infant has a laryngospasm on induction.
In Room 3, a patient is displaying signs of malignant hyperthermia following induction of general anesthesia.
An RN is "supervising" unlicensed assistive personnel (UAP) in these three rooms. Which patient needs the RN first? Where does the RN go? What does the RN do?
Well, your honor, it was like this . . . .
This scenario is coming frighteningly close, says Sandy Bean, BSN, RN, CNOR, clinical nurse II at University of California-Davis Medical Center in Sacramento.
"We have all been in ORs where incidents such as these have occurred, and we know the struggle that can ensue and how difficult it is to care for any of these patients at one time," Bean says. "We also have seen our techs fall apart at the first sign of trouble and merely stand back and watch. Without RNs caring for each patient one at a time there will be fewer RNs around to help when scenes such as this unfold.
"We don’t ask surgeons to monitor three or four cases at a time; why would you ask nurse? Why would patients deserve any less care?"
The controversy centers on the UAPs, who are trained to assist RNs in providing patient care activities as delegated by RNs. The term "UAP" includes but isn’t limited to nurses’ aides, orderlies, assistants, attendants, and technicians.
A recent study raises questions about the impact of UAPs on patient care. Implementing Nursing’s Report Card: A Study of RN Staffing, Length of Stay, and Patient Outcomes was commissioned by the Washington, DC-based American Nurses Association (ANA). The study indicated that postoperative infections, as well as urinary tract infections, pressure ulcers, and pneumonia, were inversely related to RN skill mix. In other words, the higher the ratio of RNs, the lower the incidences of post-op infection rates. The reason? UAPs are performing invasive sterile procedures inappropriately, says Anna Gilmore-Hall, RN, director of the Labor and Workplace Advocacy Department of the ANA. (For information on how to order the report, see source box, p. 83.) This study received national attention in a report broad- cast on CNN.
And Congress is getting involved. The Patient Safety Act (HR 1165) would give patients access to information on staffing and quality of care at facilities that receive Medicare reimbursement, as well as protect health care workers who blow the whistle on harmful practices. RNs who report harmful staffing decisions often are ignored or terminated, according to the ANA.
The Patient Safety Act is being studied by the House Commerce and Ways and Means committees. The ANA hopes to make the act part of the upcoming legislation package that includes proposed changes to the Medicare system.
Why the controversy?
One of the problems with the use of UAPs is that they are being substituted for licensed staff, Gilmore-Hall says.
"There’s always a role for unlicensed people to assist nurses and professionals with care," she explains. "But in today’s cost-cutting environment, rather than supplement, they are trying to substitute licensed staff with unlicensed staff, solely for the purpose of saving money. Nurses are concerned that patient quality of care is suffering."
The issue of supervising patients in more than one room is an emotional one for nurse managers.
"I’m vehemently against that," says Debbie Grunwald, RN, CNOR, medical staff coordinator at HealthSouth Aurora (CO) Surgery Center. "I will hang up my license and quit before I will put my patients and myself in jeopardy."
Bean echoes these feelings. "Now, hospitals are telling us that most of our jobs can be done by lesser trained and lesser educated technicians and that I should be able to monitor two or three patients undergoing surgical procedures at a time. To this I say, No way in hell!’"
RNs have been trained to anticipate problems and react to emergencies, Grunwald emphasizes.
Another concern is delegation of duties to UAPs, particularly since the supervising nurses are ultimately responsible for patient care, and UAPs receive no consistent education or training. In California, for example, "Some are trained on the job, some attend accredited programs, some learned in the military, and some attend nonaccredited programs," Bean says. "There is no across-the-board consistency in their education, so when you met new surgical techs, you don’t know their skills and background When you meet a nurse, all education is the same across the board."
Same-day surgery nurse managers are not opposed to delegation of some tasks to UAPs, however.
"Do I believe that some aspects of my job can be safely delegated? Yes," Bean says. "Would I like to be the one to decide which portions are delegated and to whom? You bet! As for myself, I know where my line in the sand is drawn, and my conscience will not permit me to step over it."
Determining which tasks to delegate
When deciding which tasks should be delegated to UAPs, consider state nurse practice acts, facility-specific performance criteria, practice standards, written procedures, and job descriptions written for UAPs, Dawes suggests. Nurse managers should feel comfortable delegating tasks that don’t involve nursing care, Gilmore-Hall says.
According to the ANA, delegated activities to UAPs do not include health counseling, teaching, or tasks that require independent, specialized nursing knowledge, skills, or judgment. For this reason, the following duties should not be delegated to UAPs, sources say:
• Preoperative assessment.
"I think most important for same-day surgery patients, the idea that patients are going to be in the hospital or clinic for a short period of time means they have to assessed by an RN to ensure the plan of care is appropriately developed," Gilmore-Hall says.
• Education.
Same-day surgery patients need to be prepared to take care of themselves when they get home, Gilmore-Hall points out.
"Patients may be groggy from surgery, concerned about their condition, and their ability to learn isn’t at its best," she says. "It takes a person skilled with helping patients learn to care for themselves properly. Nurses can provide that type of care, when unlicensed people often can’t."
• Postoperative assessment.
"The concern is that patients are discharged prematurely because a person hasn’t fully assessed the patient’s condition," Gilmore-Hall says. "Nurses are reporting increased readmissions and complications when patients go home."
When patients are just out of surgery and going home with wounds, the patient and family should know the signs of infection, blood loss, and dehydration, says Gilmore-Hall, who worked in a recovery room for several years. "Those signs and symptoms can be subtle. If patients are not educated properly and not told what to expect and why, serious complications can happen that don’t need to happen."
Tasks may be delegated depending on the skills of the individual UAP and the severity of the patient’s condition, she says, adding that those skills can include taking vital signs. "But that decision should be made by professional nurse, knowing what’s going on with the patient and the capability of the unlicensed personnel," she says.
Currently, nurses are being forced to delegate duties that, in their opinions, UAPs are not capable of performing, Gilmore-Hall says. Those duties include inserting catheters, dispensing medication, hanging IV fluids, and changing sterile dressings.
"Those clearly can be very detrimental to patients if not done properly," she says. (For more information on delegating patient care activities to UAPs, see the Association of Operating Room Nurses’ Official Statement on Unlicensed Assistive Personnel, inserted in this issue.)
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