Med Techs in Long-Term Health Care: Economy at the Expense of Patient Safety

_____In recent years, it has become generally believed that, for a variety of economic and demographic reasons, there is a shortage of Registered Nurses (RN) in the healthcare arena. Further, there is widespread concern that this continuing shortage could have a detrimental effect on various aspects of medical care giving. As one would expect, this concern has lead to some proposed changes in the industry. With the proposed changes, naturally, comes debate. In Ohio, a hot topic is the debate surrounding the proposal to use unlicensed medical technicians (med techs) to perform some functions traditionally fulfilled by licensed RNs. Specifically, it has been suggested that med techs be used to a greater extent in long-term care giving and assisted living. While this proposal seems innocuous on its face, it is controversial because it would allow med techs to administer medications to patients. Opponents of this measure would submit that med techs lack the training to perform this vital function, and that the use of unsupervised med techs in a role traditionally taken by RNs does nothing to eliminate the core problem, i.e. the nursing shortage. Conversely, proponents of the measure argue that precedent for the measure exists because other states have adopted similar plans. Further, proponents suggest that the system would act as a “career ladder” that would encourage med techs to move on to becoming RNs. Extensive research into this issue has led me to the conclusion that the expanded use of med techs in long term care is unwarranted. The proposed plan would unacceptably expose patients to unnecessary risks. Further, the plan would not address the underlying staffing problems that long term health care may face in the future. Finally, the idea represents an improper trade-off between quality and economy.

_____Pat Wilcox, who teaches “Adult Health Issues” at Owens Community College, brought this controversy to the attention of my nursing class. Ms. Wilcox was opposed to the idea of med techs, or Licensed Practical Nurses (LPNs) for that matter, making decisions concerning administration of medications to patients. Further, despite the current nursing shortage, use of med techs in positions formerly occupied by RNs could have a detrimental effect on the future of nursing. While I have no personal experience with this subject, I am studying to be an RN. Accordingly, the outcome of the med tech debate and a clear understanding of the broader underlying issues could impact my career.

_____Med techs are essentially a type of unlicensed assistant personnel (UAP) that currently exist throughout the healthcare system in great numbers. These UAPs are often used to perform nondiscretionary or menial tasks. In addition to not being licensed, UAPs are not regulated (Helm). Typically, a UAP has minimal training (Ventura 14). Consequently, UAPs generally command smaller salaries than RNs.

_____On its face, the simplicity of the proposal makes it seem somewhat harmless. The plan to extend the use of med techs in long term health care seems, at first glance, to be reasonable. In fact, without further scrutiny the plan may even seem warranted. Why not have unlicensed med techs become more involved in the extended health care setting? After all, with the perceived shortage of health care professionals, would not the extra help provided by med techs be a blessing for all concerned? Look deeper at the proposal or even its underlying premise, and one see the proposal is not without latent pitfalls and potential hazards.

_____The proposal derives from a simple premise. The needs of extended or long term health care are not being efficiently met. Proponents of the use of med techs argue that over-regulation of RNs makes their use in extended care impractical (“OBN”). Further, cost is an issue. Many states, in effort to combat costs, have offered types of Medicaid to allay the costs to the patient (Mella 54).

_____The most prevalent justification for proponents of the plan, however, is the perception that a nursing shortage exists (“Minutes of Meeting”). This perception, however, is subject to some dispute.

_____Advocates of the med tech plan claim that the use of med techs would combat the nursing shortage in two ways: First, they argue, the use of med techs in long term care would alleviate the manpower pressures being exerted on health care professionals (“Minutes of Meeting”). Secondly, it is argued, med techs may use their experience in long term assisted care as a “career ladder.” In other words, the med techs would move on to fill the nursing shortage.

_____Is there a nursing shortage? If so, is the introduction of med techs into areas traditionally filled by licensed healthcare workers the solution?

_____There seems to be some debate over the existence of a shortage of nurses. According to a 2001 report by the Ohio Nurses Association (ONA), Ohio licensed more nurses between 1997 to 1999 than in previous years (“Ohio Nurses”). Peggy Noble, a government affairs specialist with the ONA, stated that “the fact is this- there is indeed a nursing shortage out there- and it is primarily at the patient's bedside. Nurses who are tired of drastic and unsafe working conditions are leaving the bedside to work in other areas of health care” (PSNA).

_____Admittedly, the ONA is a vocal opponent of the med tech plan. Nevertheless, at least one prestigious and unbiased source agrees that a shortage does not currently exist. The Congressional Research Service has formed that no shortage of nurses will exist before 2008 (“CRS” 7). According to the CRS study, there was actually a surplus of RNs as recently as 1998.

_____Despite the ONA and CRS findings, there is significant evidence of a nursing shortage. Recently, the demand for nurses in some areas has outpaced supply, resulting in a shortage (Tieman 40). In fact, the United States Congress is sufficiently concerned by the prospect of a nursing crisis that both the House and Senate have recently passed bills aimed at addressing the problem. Both the Senate and the House versions offer various economic incentives to encourage more persons to consider nursing as a career (“Nursing Shortage Bills Approved”).

_____Data Compiled by the Ohio Hospital Association's (OHA) website suggests that a shortage of trained nurses does exist in this state. According to a “whitepaper” issued by the OHA, the Ohio shortage will become critical by 2010. Unlike previous shortages in the nursing workforce, the OHA argues that the present shortage is not “linked to large numbers of nurses choosing not to work.” Fewer people are choosing nursing as career according to the OHA. Meanwhile, the demand for trained caregivers is increasing.

_____The Ohio Nurses Association (ONA) dispels the OHA's data as self-serving. The ONA suggests that the OHA needs the specter of nursing shortage to fight legislation calling for safe staffing and curbing mandatory overtime (“Ohio Nurses”). Undoubtedly, the existence of the prospect of an impending catastrophe in nursing staff levels would help proponents garner support for the med tech idea.

_____In truth, the existence or nonexistence of a crisis in licensed personnel is not a sufficient excuse to adopt the med tech system. If one were to assume that the staffing demands of the extended care industry were not being met, the provision for the placement of unlicensed techs into jobs traditionally occupied by nurses would not be justified. Long term or extended care facilities, while often considered markedly different, have a good deal in common with acute care facilities like hospitals (Feldkamp 61). Many patients in long term care facilities require extensive medical care. According to Janet Feldkamp, “the complexity and acuity of illness seen in nursing home residents has been on the rise” (61). Significantly, unlike acute care facilities, extended care facilities often place RNs in a position of oversight (Feldkamp 61). Potentially, in many cases, the RN is the highest ranked professional on duty at a long term care facility. In addition to her normal duties, a RN may have the responsibility for delegating assignments to UAPs.

_____Unlicensed assistant personnel (UAP) already exist in significant numbers in the long term health setting. Under the current system, RNs have a significant delegation authority over UAPs. Currently, the rules governing delegation of tasks to UAPs are clearly defined (“Registered Nurse”). Expanding the role of med techs in the long term care facility might blur the established bright lines of what can be properly delegated.

_____The most controversial aspect of the med tech plan is the fact that the under trained techs would make assessments and administer medication to patients (Goldner). Organizations, such as the American Nurses Association, are steadfastly opposed to the use of UAPs in the performance of tasks within the legal practice of nursing. The major problems, according to critics like the ANA, are the actual threat to patient safety (“Registered Nurse”).

_____Med techs, like other UAPs, lack the underlying training required to make assessments routinely made by RNs. Lack of training can lead to dire consequences. As Ann Helm, a lawyer and an RN, writes in “Liability, UAPs and You”, the use of UAPs carries significant risks. Helm described a UAP that gave a hot water bottle to an 89 year old quadriplegic. The UAP used water from a coffee maker that was approximately 200 degrees Fahrenheit. The patient took a year to recover from the resulting injury (Helm). Just imagine the type of consequences that would result from using a similarly trained person to make assessments and administer prescription medications.

_____Lack of licensing requirements also brings significant risk to a patient as a general rule. While RNs are, by law, subject to vigorous oversight by the Board of Nursing, and stringent licensing requirements (see Ohio Revised Code: Chapter 4723), med techs are unlicensed, and largely unregulated. The regulations and license requirements governing RNs protect the public. Stringent requirements ensure that each RN has met an established minimum necessary to provide for patients. A 1999 article in RN magazine showed the staggering 23% of UAPs received less than 1 week of training (Ventura 14). Further, patients are often left uninformed about the persons treating them. Many times, patients wrongly assume that a UAP is an RN (Schiff 17).

_____Regulations insure that the conduct of RNs meets or exceeds that expected by the profession. An RN that physically abused a patient would be subject to professional discipline. Further, the hurdle of the legal requirements posed by Ohio law help lower the risk that RNs are potential “bad apples.”

_____Conversely, med techs are not subject to stringent licensing requirements. Theoretically, anyone could become a med tech. The potential for a “bad apple” to become a med tech is greater. Further, the lack of licensing makes the unscrupulous med tech harder to detect. Helm writes about the unlicensed medical assistant that murdered his 60 year old patient. The agency that hired this person was unaware of his previous felony convictions, and the fact that he had been previously fired from similar jobs (Helm).

_____The proposed use of med techs to administer medications is not the answer to the perceived nursing shortage. Proponents have argued that the use of med techs would, in essence, be a “career ladder.” Under the “career ladder” concept, med techs would, for annunciated reasons, choose to further their career in the healthcare field by seeking more education and licensing. The Ohio Health Care Association (OHCA) is a supporter of the “career ladder” proposal (“Where”).

_____At best, the “career ladder” justification proposes a “quick fix”; at worst, the program will only exacerbate the current problem. While proponents suggest that the use of med techs would actually combat the nursing shortage, no empirical evidence exists to support this. In fact, some evidence suggests that the shortage would never actually be addressed. In a discussion before the Ohio Board of Nursing in July 2001, Ella Kick of the Ohio Board of Nursing commented that in other states, such as Indiana, med techs would leave the long term care setting as soon as they became experienced, “and long term [healthcare] was back to square one” (ONA). The ONA's representative to the July 2001 discussion agreed: “as for the idea of a career ladder-either a person is predisposed to likely further their education or they are not. I do not see how taking a few weeks of a drug course would change a person's mind about a career path” (“OBN”).

_____The OHCA also bases its support for med techs out of dissatisfaction with a perception that “ RNs are tied up with regulations, and regulations are an impediment to nurse recruitment” (“OBN”). This argument seems to ignore the purpose of many of the regulations. While, undoubtedly, many regulations may seem like bureaucratic overkill, they serve the all important function of insuring quality care giving in both the acute care and long term care setting.

_____Currently, the med tech issue is still up in the air. No legislation is currently pending on the issue. According to Pat Schecht of the Ohio Board of Nursing, the OBN has not taken a stance for or against the issue. If legislation is passed, said Ms. Schecht in a phone interview on May 6, 2002, the Board would recommend that the med techs receive a minimum of four weeks of training. Further, the Board would seek regulatory oversight of the med techs.

_____As indicated above, the ONA is opposed to the creation of med techs. The ONA is joined in its opposition by organizations such as the Tri-state Oncology Nursing Society, the Ohio Organization of Nurse Executives, and the Ohio League of Nurses. These associations are obviously pro-nurse. However, other nonprofessional organizations have voiced opposition to the med tech proposal. For instance, the OHA, Hospice, and Mental Retardation/ Developmental Disability (MR/DD).

_____The OHCA is the chief proponent of the idea. The OHCA seems to be virtually alone in this support. The OHCA is involved in the long term care business. Left unsaid in the debate is the comparative cost of using med techs as opposed to licensed professionals. Undoubtedly, if there is a nursing shortage, the laws of supply and demand would dictate that med techs would offer a significant savings to the long term healthcare industry. It is possible that the OHCA's position is, at least in part driven by the prospect of cutting costs.

_____The proposal to expand the use of unlicensed med techs in the long-term health care setting is a bad idea. Making assessments of patients and administering medications are not menial tasks. Too much discretion for key decisions would rest with persons who lack the requisite training and qualifications. No empirical proof exist that would sufficiently show that using med techs in this expanding role would cure problems associated with a nursing shortage. Ultimately, the driving force behind the plan may be simple economics. Patients, whether in a long-term or an acute care setting, deserve better.

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