As the hospital industry attempts to deal with a shortage of nurses who are willing to work at the hospital bedside in Massachusetts, the Massachusetts Nurses Association has been on the lookout for the implementation of management strategies that attempt to deal with the shortage by replacing or substituting registered nurses with lesser qualified, unlicensed personnel. Such practices have been utilized in previous shortages with disastrous results, and in a number of reports and studies, such practices are cited as a cause of the current shortage we now face.
Last month, the Massachusetts Nurses Association sought and obtained a written opinion from the Massachusetts Board of Registration in Nursing regarding just such dangerous and misguided policies being implemented by the three Massachusetts hospitals that call for expanding the use of paramedics inside of hospitals to substitute for nurses in both intensive care units and emergency rooms.
The advisory from the BORN provides important guidance to nurses and nurse administrators that prohibits any delegation of nursing duties or tasks that require the judgement and assessment of a registered nurse to paramedics in the hospital setting. In the ICU, it is clear from the BORN advisory that paramedics cannot function beyond the scope of a typical PCA or nurses’ aide. In the emergency department, if a paramedic is to perform any duties beyond the PCA role, they can only do so under the direction and supervision of an MD. No nurse or nurse manager can delegate registered nursing duties of any kind to a paramedic without being in violation of the Board of Registration’s nurse practice act.
The MNA sought the ruling by the BORN after it learned of a program being implemented at the MetroWest Medical Center, a hospital owned by for-profit Tenet Corporation in Natick, which called for the use of paramedics in the intensive care unit to perform a variety of functions that are the exclusive purview of the registered nurse. During the same time period, the MNA was alerted to a similar programs utilizing paramedics to assume nursing functions in emergency departments at Lawrence General Hospital. The MNA is also clarifying the use of paramedics in the emergency department at Merrimack Valley Hospital in Haverhill.
At MetorWest Medical Center, management created and filled positions with the title, "ICU Paramedic." Under the supervision of the unit’s nursing management, the position job description clearly states that the ICU paramedics contribute to the "assessment, planning, implementing and evaluation of patient care."
The ICU Paramedic job description includes a number of functions that the MNA believed clearly fall only to RNs to perform, including: auscultation of breath sounds, heart sounds, initiation of oxygen therapy, analysis of cardiac rhythms and monitoring patients with Swan Ganz catheter; chest tubes; or cardioversion and sunctioning of patients.
The letter to the MNA from the BORN’s Nursing Practice Coordinator Gino Gisari, MSN, RN, stated that none of these activities comply with the Board’s criteria for delegation. If a nurse were to follow the hospital’s job description and delegate these tasks to one of the ICU paramedics, according to this ruling, he or she would be violating the Nurse Practice Act.
The MNA also asked for clarification as to the responsibility of nurse managers in allowing or sanctioning this level of delegation. The Board’s response was again quite clear. The ruling states, "The regulations governing licensed nurses are the same regardless of job title or employment setting."
According to Dorothy McCabe, MNA Director of Nursing who initiated the discussion with the BORN on this issue, "There is no ambiguity here, this job description, as written, is in direct violation of the nurse practice act. Any nurse manager who participates in supervising paramedics in performing at this level, and any nurse who allows a paramedic to perform these tasks on their patients, is in direct opposition to and in conflict with the Board of Registration’s position on delegation."
In another case, nurses at Merrimack Valley Hospital raised concerns to the MNA and with management when a paramedic assigned to the emergency department transported a patient to the ICU and proceeded to give a nurse orders for that patient. The nurse wisely refused to accept the orders from a paramedic and insisted that she would only take orders from a physician.
Based on the BORN letter to MNA and on subsequent conversations with offcials at the BORN, it is clear that the nurse acted accordingly. If and when a paramedic is working in an emergency room, they can only work under the supervision of the physician. If a paramedic works with a nurse, he or she can only function at the level of a PCA or traditional nurses aide.
At Lawrence General Hospital, the MNA local bargaining unit became involved in the issue when the husband of one of the nurses, himself an EMT, became alarmed upon bringing a patient into the hospital’s emergency room only to be greeted by a paramedic who wanted to admit the patient. The EMT refused, stating that he would and could only turn his patient over to an RN. A nurse manager stepped in and allowed the paramedic to admit the patient. Again, this is in violation of the Nurse Practice Act and JCAHO standards, as it is only a nurse who can admit and take a history of a patient in a hospital setting.
"We became alarmed to see a pattern of behavior that signaled to us that the hospital industry was once again responding to a shortage of nurses by seeking to implement strategies that called for the replacement or substitution of RNs by lesser qualified, cheaper substitutes—in this case, paramedics," said Karen Higgins, RN, president of MNA. "We have been down this road before, during the 80s and throughout the 1990s and it was disastrous for both nurses and for patients. In fact, these policies are what created the current shortage. We have nothing against EMTs and paramedics. They serve a valuable role in providing pre-hospital care. But they are not and cannot function as a registered nurse."
The MNA’s position is supported by a number of studies, including two recent studies published in the New England Journal of Medicine and the Journal of American Medical Association, which both found that when there is a skill mix with fewer RNs, the quality and safety of care is negatively impacted.
"The bottom line is, if you want to provide safe, quality patient care, there is no substitute for a registered nurse," Higgins said. "Our hats are off to the Board of Registration in Nursing for reinforcing that concept. Now it is up to every nurse and nurse manager to stand up for quality patient care and to not allow misguided administrators to attempt to destroy nursing practice by handing our practice over to lesser qualified personnel."
A copy of the MNA publication "Accepting, Reflecting and Delegating a Work Assignment: A Guide fro Nurses," can be obtained by calling the department of nursing at 781.821.4625. A free 1.2 contact-hour program can be scheduled at your facility by contacting Dorothy McCabe at 781.830.5714 or via e-mail at dmccabe@mnarn.org.
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