Legislating the duties that can be performed by a nurse

Recently the Michigan Task Force on Nursing Practice hosted a regional forum in my area.  I was fortunate enough to attend and hear from the RN’s there the many issues that they face, which are varied and challenging.  The state wanted to hear from this forum of RN’s what changes were needed in the state’s nursing regulations so that certification could be updated to reflect the current nursing environment.  It had been over 20 years since the state had updated its current standards and regulations.

At the table where I was sitting one group of nurses was complaining that all too often at the hospital where they worked a nurse would be reassigned to a different department or floor from the one where they normally worked.  For instance a nurse who might normally work in oncology would be reassigned to pediatrics for one shift in order to fill a shortage of nursing staff in pediatrics.  The nurses complained that they often felt uncomfortable and unqualified to fill in.  Of course the hospital had the right to make these assignments as there are no regulations forbidding such a change.  Doing so might increase the likelihood of errors.

In response to this complaint another group of nurses who worked at a different hospital stated that they were rarely if ever pulled from the department in which they worked.  They were employed by one of the larger hospitals in my locale.  This hospital has a reputation of working diligently with staff on patient safety and quality.  One of the common approaches used is Lean Six Sigma for continuous quality improvement.

When the nurses from all of the tables were reporting on the current state of affairs in nursing, it seemed that a recurrent theme was the appalling extent to which medical assistants and others were performing activities which formerly had been done primarily by RN’s.  They thought that it might be time for the state to enact legislation to counter the alarming trend.

As I listened to the discussions I questioned to what extent a state should legislate the duties that can be performed by a nurse.  Certainly the state should determine the qualifications through education and testing of the various certifications of clinical staff, including RN’s.  Too it should restrict some clinical duties to RN’s and physicians, such as the injection of certain medications.  In my opinion, though, a state should be careful in its restrictions so as not to create unnecessary burdens on institutions where nursing activities are necessary but funding is inadequate to allow the employment of RN’s.

Rather than focusing on certification to achieve quality and safety, I believe that these can be achieved at healthcare sites that have them as primary goals.  Having safety and quality as goals is not enough though.  Principles must be put into action.  This is not simple.  Ensuring the quality of care and safety that greatly exceeds legislated minimums requires daily efforts to improve the delivery of healthcare by all providers.

The work of daily improvement of outcomes for patients is complex.  I would like to briefly describe what I believe are two very important elements of this daily effort.  One is leadership.  The other is standardization of work.

Leadership from the top is a must in continuous quality improvement efforts.  When upper management insists on quality and demonstrates it through their own activities, then quality activity will most likely proceed on a daily basis.  From my own experience in coaching quality managers I have seen the necessity of top managements’ support in order to overcome the reluctance of some staff to change in order to improve the delivery of care.

Standardization of work is another approach that ensures the continual improvement of quality outcomes.  The University of Michigan Health System and Hospital make extensive use of this.  For instance, the hospital staff has standardized the handoff of patients from post op recovery to the nursing staff of the floor where they will be until discharge.  The floor supervisor is a leader in this process; the standardization of the process ensures that communication of postoperative care procedures are clear to all involved.  While the nursing staff understand that the handoff procedure is standardized and that all new nursing staff are trained to follow the handoff procedure, they also expect that each staff member will continue to examine the process so that it can b e further improved.  Under the guidance of nurse leaders suggested improvements from the staff are examined and then implemented if such changes improve the care of the patient.

All healthcare sites should strive to create a culture in which management and staff focus daily on improving outcomes for patients.  This is very challenging in light of all the new requirements from the Federal government such as the implementation of new HIPPA standards and ICD-10 coding.  However, even these demands can be viewed as an opportunity to improve outcomes for patients and for their healthcare site.  Resisting the demands for improved quality outcomes will lead to lower income for providers whereas improved outcomes will be rewarded in many ways.  As Kathy B. Dempsey, a keynote speaker at the fall Michigan MGMA conference said, “Shed or You’re Dead.”  That is, shed your current state of thinking and embrace new modes of working and thinking or be left behind.

Donald Tex Bryant is a consultant who helps healthcare providers meet their challenges. He can be reached at Bryant’s Healthcare Solutions.

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