Controllers and nurses butt heads in California
Skin-testing controversy in hands of lawmakers
California lawmakers are close to sealing the fate of a bill that state public health experts say is crucial to the future of TB control. The bill seeks to legitimize a practice already widespread throughout the country — namely, letting outreach workers perform tuberculin skin testing.
Several professional organizations in the state, including a state physicians’ association and an association of public health nurses, have come out in support of the measure. But the California Nursing Association has mounted a heated campaign against it. What especially piques the nurses’ group is the way the bill seeks to create a new category of health care specialist, that of "certified skin-test technician." The measure is expected to go before the California general assembly in late June.
Given the shortage of both registered nurses and public health dollars, advocates say the nurses’ group is waging a misguided battle over turf. "Here in San Francisco, we’ve used unlicensed personnel to place and read skin tests for over two decades, and many other counties in the state do so as well," says Masae Kawamura, MD, medical director for the San Francisco County TB control program. "If we had to use registered nurses to do this, it would really kill our program."
Like many other states, California TB control is working to keep the focus on case detection and contact investigation, while at the same time stretching its resources to include targeted testing. Estimates put the number of people latently infected with TB in the state at between 3 million and 4 million, which translates to least 340,000 active cases, notes Bob Benjamin, MD, interim health officer for Alameda County and president of the California TB Controllers Association (CTCA). Finding a way to meet the need for targeted testing of that immense pool is an urgent priority, he adds.
The subject of using unlicensed personnel to conduct skin testing has been dormant for years, Benjamin explains. "It was sort of a gray area, and we’d kept quiet about it for many years," he says. But nurses in some counties in the state were uneasy about the practice, he concedes. Guidelines from the Centers for Disease Control and Prevention (CDC) in Atlanta are silent on the subject. So about a year ago, the CTCA decided to address the problem head-on, he says.
The bill the association crafted was intentionally designed to encroach on nurses’ turf as little as possible, Benjamin says. For example, it proposes that skin-test technicians would be used solely in public health settings; that they’d be trained and overseen by registered nurses; and that they would place and measure, but not read, the tests. In addition, the bill makes clear that the use of employees is strictly optional, and that counties which need not, or wish not, to use the techs are in no way required to do so.
But the nurses’ group says that part of the problem involves the high level of skill required to place and read the tests. But with skin testing, says Benjamin, it’s experience — not a nursing license — that counts the most. "There are plenty of physicians and nurses out there whose ability to perform a skin test I wouldn’t trust any further than I could throw an elephant," he says. "Just as I’d want my knee surgeon to be the person who’s done 10,000 surgeries and not just one, I want someone doing skin tests who’s got lots of experience doing them. Here, it really is a case of practice makes perfect."
But the nursing association disagrees. "We’ve seen no compelling scientific data to show it’s being done safely," says Sara Nichols, JD, a legislative advocate for the nursing group. Plus, Nichols argues, adding yet one more category of worker with narrowly defined skills and duties further erodes the role of nurses.
"For the last 20 years, there’s been a trend in the private sector toward fragmentation of health care delivery," Nichols says. "Ostensibly in the name of cost-cutting, we have all these workers who are trained to do only one or two things." This "de-skilling" of nursing is driving nurses away from the profession, she adds. "We think it’s better for patients to have a skilled nurse who’s trained in a variety of arenas; and we think that nowhere is that more important than in public health. Let’s not let it drive them out of the public sector as well."
To Benjamin, that point is moot, since TB controllers can’t afford to indulge it. "I have the greatest respect for professional nurses, and yes, I’d love them to be involved in every facet of the job," he says. "But given the shortage of nurses and the shortage of funds, I’d rather reserve nurses for the highest-level tasks, and let outreach personnel do this particular job."
The argument reminds Benjamin of an earlier battle over a different subject, he adds. "I remember very clearly the days when physicians were reluctant to let a nurse start an [intravenous line]. But in reality, my job as a physician hasn’t been threatened or diminished by the decision to let nurses and IV techs start IVs."
Likewise, if TB controllers had the money to fill outreach positions with registered nurses, that would be great, he adds. "But the fact is that we don’t have enough nurses, and TB isn’t going away. This bill isn’t a threat to nursing," Benjamin adds. "It’s a means to broaden our ability to address a devastating disease. With this bill, we could all win."
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