“Relieving the Registered Nurse”: CA Assembly Bill 704 and the
Geriatric Health Care Assistant
By Kara Kidd, BSN, RN
CNSA Legislative Director
A Summary of the Bill:
On April 4th, 2005, California Assembly-member Mervyn M. Dymally introduced a bill proposing the creation of a geriatric healthcare assistant. The bill would allow Certified Nursing Assistants (CNAs) with additional hours of training to administer medications to residents in skilled nursing facilities. Specifically mentioned in the bill were enemas and suppositories.
According to the bill’s author, the primary function of these new, certificated personnel is “relieving the R.N.” This would allow them to provide additional care which absolutely requires advanced education and skill, such as assessment. The primary duties of such personnel would center on “personal care and comfort functions for the elderly.” Many of these functions including assistance with mobility, bathing, care of hearing aids, glasses and other prosthetic devices—tasks previously carried out by the CNA. With only a few additional hours of training, the Geriatric Health Care Assistant position would expand the traditional CNA job description to include administration of medications.
To qualify, the individual must submit an application for certification to the Board of Vocational Nursing and Psychiatric Technicians and pay the application fee. In addition, the applicant must be able to prove that they have been employed on a full-time basis in a geriatric residence for at least 12 consecutive months, where they have been working under the “supervision of a resident nurse” (i.e. a licensed vocational nurse), and that they have received on-the-job training.
The bill went before committee November 17, 2005, when the merits and the drawbacks of the Geriatric Health Care Assistant were discussed.
So What’s This Really About?
Like many smaller institutions, the skilled nursing facilities (SNFs) are feeling the pinch of the nursing shortage. The SNFs are unable to compete with the higher wages and better benefits available to the R.N. in acute-care settings. Consequently, the SNFs are finding it increasingly difficult to retain their licensed professionals, creating something of a cycle; the inability to keep qualified professionals lays a heavier burden on those that remain. As a result, the remaining nurses burn out and leave, further perpetuating the cycle.
This bill would allow the skilled nursing facility to use unlicensed assistive personnel (UAP) to administer medications. The author of AB 704 believes that the creation of this new certificate will ease the burden, freeing the nurse to address other responsibilities (assessments, etc.) which cannot be performed by other personnel. Dymally hopes that passage of this bill will help address the nursing shortage within the SNFs and create a better work environment. But what about a better care environment?
My Two Cents…
This is a short-term fix—and a poor one at that. Providing less nursing care to the geriatric population is not a solution to the nursing shortage. In fact, less nursing care has been directly tied to increased adverse medication events and poorer patient outcomes—which would ultimately necessitate more care, not less. A more sound solution would be to address the conditions that prevent skilled nursing facilities from retaining qualified personnel.
This bill is cause for concern, as it grants the legal authority to administer medications to unlicensed personnel. It begs the question, “Who will bear the responsibility for errors made by the Geriatric Health Care Assistant?” We know that as registered nurses, when we delegate, we must take into consideration the complexity of the task, the skill and education level of the individual to whom we are delegating the task, as well as the limits of their scope of practice or job description before granting them the authority to carry out the task—and in the end we bear the ultimate responsibility for the outcome.
Before we administer any medication, we first assess—a skill which is solely in the scope of the registered nurse. While the administration of enemas and suppositories may be relatively safe, there are conditions under which we use nursing judgment to determine whether it’s in the patient’s best interest to withhold any given medication. Even with additional hours of training, the CNA would not have the knowledge base to make this determination.
To allow unlicensed personnel to administer any medication creates the potential for the “slippery slope phenomenon.” After all, if it’s okay for the unlicensed person to administer an enema, then why not a stool softener or other medication?
Why Not…
This bill, like many other staffing issues that involve the expansion of duties of UAP, can be traced back to the shortage of qualified nurses, most particularly the registered nurse. In less than 5 years California will face a deficit of over 50, 000 nurses. As a result, the pay at acute-care facilities will continue to rise and skilled nursing facilities are unlikely to be able to keep up with the increases in wages and benefits.
Instead of creating new unlicensed positions, why not make a concerted effort to increase the numbers of those that are most desperately needed—registered nurses. The governor’s commitment of $90 million to nursing education is a first step in the journey to alleviate the dearth of qualified professional nurses in California.
What Do You Think?
This topic is the first of many to appear on the legislative discussion board. Please log on to cnsa.org and share your thoughts on expanding the role of UAP. I look forward to a lively discussion.
