by Susan Trossman, RN

The staffing shortage is real. So are the increasing attempts to assign RN responsibilities to school secretaries, EMT-like staffers and questionably trained medication techs -- all in the name of "the RN shortage."

The issue of encroachment is not new to the nursing profession. But some nurses are worried that, given current hard times, institutions will gain virtual carte blanche to replace RN positions while continuing to ignore some of the major reasons behind staffing problems. Those reasons include short-sighted restructuring schemes, poor working conditions and a failure to recognize the important contributions RNs make to the ongoing health of patients, schoolchildren and other health care consumers.

"Nurses have always known that RNs truly have the knowledge and skills to provide quality care. We also now have a growing body of evidence that shows that appropriate RN staffing has a positive effect on patient outcomes," said Nevada Nurses Association (NNA) President Cynthia Bunch, RN. "Hospitals have had the opportunity to increase pay, make scheduling more flexible and make the working environment more attractive. Yet I just see the health care industry going back and repeating the mistakes of the late '80s and early '90s by replacing RNs with lesser skilled personnel, such as medication techs and feeders in nursing homes.

"How low do they want to go?" Bunch asked.

The following are just a few examples of the battles that ANA constituent member associations are fighting on the RN replacement front.

Diverting the issue

It started about three years ago. Hospitals in Las Vegas routinely were diverting ambulances from their emergency departments and making walk-in patients wait record times because of a shortage of beds, and moreover, a shortage of nurses in ERs and ICUs.

This summer, a task force, whose members included representatives from the Nevada Hospital Association, ambulance companies, several state agencies and NNA, was formed to develop a remedy to the region's ER woes. The task force decided to "fill in" the RN shortfalls with ER techs -- despite arguments from Bunch that there were experienced, specialty nurses available to provide care to patients.

When the task force first began meeting, the ambulance companies' management asked if NNA could get input from ER nurses on the shortage issue, Bunch said. What she learned from them was that, in general, there were enough RNs to work in the ERs. It was hospital administrators who were not renewing the contracts of local agency or traveling nurses who had the expertise to provide the much-needed care.

"Agencies generally charge twice as much as what hospitals pay their staff nurses," Bunch said. "So it's really a budgetary issue. Hospital administrators are choosing not to spend their money on agency nurses or make changes in the work environment that would allow them to hire more staff nurses."

With that information in hand, task force members still discussed filling the ER staffing shortages with paramedics, until they decided that paramedics also were in short supply.

The task force ultimately approved a plan that would allow hospitals to create the position of "ER tech" -- a move that the state supported. While task force members suggested that persons with EMT training would be preferred candidates for these new positions, they stated that ER techs would not carry the EMT title or have its scope of practice, according to Bunch.

Members also attempted to formulate a job description for the new position, playing with the idea that ER techs would be responsible for many of the same tasks assigned to certified nursing assistants -- with a few additions, such as performing EKGs and venipuncture. Again, the task force handed over that decision to hospitals, saying management there should determine the actual role of ER techs, as well as their training.

Bunch added that the Nevada Board of Nursing did not object to RNs supervising ER techs, as long as the nurses did not delegate core nursing responsibilities, such as evaluation, assessment and case management.

Bunch said she is not surprised with the creation of the new ER tech position, because the hospital industry has been advocating for this measure for close to a decade. But she is worried that there is nothing preventing hospitals from using ER techs on other units.

Noting that respiratory therapists already have been trained to provide more services in some ICUs, Bunch said, "Hospitals can take this anywhere they want to."

Injecting non-nurses into the equation

This fall, California Gray Davis vetoed a measure that would have required school administrators throughout the state to designate two employees at every school who would administer insulin and glucagon to children with diabetes when needed.

Introduced by State Assemblyman Marco Firebaugh, AB 481 also would have required these employees to test and monitor blood glucose levels if the children were unable to do it themselves.

Davis's veto is a victory of sorts for nurses. Lydia Bourne, ANA\C legislative advocate and a former school nurse, testified against the bill at several state hearings and led a campaign by ANA\C nurses to fight its passage.

It was the second time this measure was introduced in the state legislature, and it probably won't be the last, according to Bourne. Many legislators seem willing to ignore that current federal law already has protections in place for diabetic children or that insulin management requires highly tuned assessment skills. Instead they appear easily swayed by the argument that school employees can administer insulin because "moms do it" and the "needles are small."

But Bourne considers insulin the most dangerous legal drug on campus.

California School Nurses Organization member Sharon Thompson, M.ED., RN, agrees. Thompson just retired as the school health coordinator of Riverside County, CA, and now works one day a week performing special assessments for the district's alternative education program.

"The new types of insulin available react so quickly that even the children can't tell they have too much insulin on board until they are in trouble," she said. "And in hospitals, insulin administration is the No. 1 error, even with a second nurse double-checking the dosage. So how can a school district ensure that students will be given the right dosages? They'd have to be trained to a 'T,' and still RNs are better trained than school personnel could ever be."

In the end, the California bill was vetoed largely because of its cost and an issue of liability.

"I know it's going to rear its ugly head again," Thompson said.

In Tennessee, however, legislation passed this year that gives school districts the authority to decide if they want to appoint an unlicensed person in each school to administer glucagon to schoolchildren.

The original bill was proposed at the urging of a parent of a diabetic child who feared that the school nurse, who had to travel among several schools in rural Tennessee, would not be available to administer the life-saving drug in the event of an emergency, according to Mary Kornguth, PhD, RN, NCSN, chair of the Tennessee Nurses Association's (TNA's) Committee on School Health.

She said that when the proposal came before her committee, its members were divided on a course of action. Some nurses believed it was important to not block a measure that could save a diabetic child's life. On the other hand, other nurses believed that the administration of glucagon required the assessment and monitoring of a licensed person.

TNA decided to neither oppose or support the bill, but instead offered alternate language to the measure, which was eventually accepted. Specifically, school districts, themselves, can decide whether they want to appoint an unlicensed person to administer glucagon, as opposed to earlier legislative language that would have mandated them to do so. Further, training on glucagon administration must be done by a registered nurse in accordance with state protocols, including those established by the public health department, according to Kornguth, who described this as a "hot potato issue."

"Most school boards will probably go along with this plan," she said. "But we're asking school nurses to look at all the issues -- such as the availability of parents or EMT services to administer the glucagon -- before they suggest their school districts implement this strategy."

Bourne and Thompson see the recent California proposal as yet another attempt to substitute RNs with lesser prepared staff -- regardless of the potential negative outcomes. They also believe that policy-makers and others will use the nursing "shortage" as an excuse for pursuing more initiatives that encroach on nurses' practice in their state.

Bourne said that there is no documented shortage of RNs who want to pursue careers in school nursing.

When surrounding counties have posted open school nurse positions, they have had a good selection of applicants to choose from, Thompson said.

Added Kornguth, "It's important to articulate what we do as nurses. The lay public sees pills and injections, they don't understand the quality of our assessments, our critical-thinking skills."

Long-term care, short-sighted solution

The specter of medication techs being used in Ohio long-term care facilities has been floating around for several years. But in the summer of 2001, there actually was draft legislation being circulated at the Statehouse, according to Beth Bickford, MS, RN, CNS, Ohio Nurses Association (ONA) projects and technology program director.

When ONA learned about it, the ONA board immediately created a Rapid Action Team to defeat the legislation. Headed by ONA board member Rae Arnold, MA, RN, team members began gathering as much information as they could on the 22 states that currently utilize medication techs.

What they found was that while practices differed from state to state, there virtually was no quality assurance programs in place to prevent medication errors.

"Long-term care administrators and state authorities said that they hadn't heard of any problems with techs administering medications, so there must not be any," said Bickford, who has been providing staff support to the Rapid Action Team. "But we weren't comfortable with that type of oversight."

The nursing home industry eventually dropped the legislative proposal, becoming sidetracked by a bill designed to reduce their liability insurance costs.

But ONA did not become sidetracked.

The team recently developed targeted informational packets for legislators, politically active nurses, nurses in general, and the public at large, Bickford said. In addition, the board authorized funds to defend against this threat of encroachment on nursing practice.

"What we saw in that draft was scary," Bickford said. The medication techs would have been able to administer oral, topical and injectable meds. There was no pre-set curriculum to train them, and it was up to the facility to provide the training. Also, the med techs would have worked at the direction of the nurse -- so medication administration still would be nurses' responsibility.

Bickford added that some long-term care directors of nursing have supported the measure, because they contend it would free up nurses to do other important tasks, like patient assessments and management of complications.

"We have our doubts," she said. "They'll probably be spending more time on MDSs (required paperwork for Medicare reimbursement)."

Like other nurses, Bickford believes that the staffing shortage is giving efforts to replace RNs more legs these days.

"The hospital and long-term care industries are getting the attention of legislators by saying there aren't enough people. They say they want all the hands they can get," Bickford said. "We say we need to improve working conditions and help people go back to school -- not decrease the preparation people need to perform these highly skilled tasks.

"Unfortunately, state lawmakers think of the nursing scope of practice in terms of tasks, and we know that if you take away a task like medication administration from nurses, then you will take the nurses away from the patients."

Susan Trossman is the senior reporter for The American Nurse.