I am a LPN, currently going back to school for my RN, who works as a float in a large multi-specialty and primary care clinic. When I say large, it's pretty much the only game in town as far as ambulatory healthcare goes, and we have partnerships with all of the major hospitals. I'd venture a guess that a good 80% of the nurses in my city work for this clinic. I mention this to give you all a sense of the scope of the problem I'm talking about.
I have been here a little over 3 months. On my first day, I was surprised to find that I was being trained not by another LPN or RN, but a Medical Assistant. I was also taken aback when I heard her repeatedly refer to herself as a nurse when she interacted with patients. Given it was my first day, I didn't think it was the time or place to say anything, and I assumed it was just an isolated issues with that one person.
I soon found out this was not the case.
In my clinic, anyone who wears scrubs is, apparently, a nurse. According to just about everyone, from the self-proclaimed "nurses" to the highest levels of management.
From what I have gathered, the clinic was originally staffed by LPN's and RN's, but this got too expensive. So they just started hire anyone off the street, give them on the job training, and call them an "office nurse". Since they were working under the MD or NP's license, they could get away with this. Now the rules have changed and they have to hire certified medical assistants-but this is a recent development. The un-certified laypeople (I'll call them UCLP from hereon out, for brevity sake) were grandfathered in, and still comprise a good chunk of the "nursing staff". To make up for the new demand for CMA's, a handful of for-profit schools quickly created MA programs and started churning out graduates who were willing to pay 15k for 6 months of training that consists mostly of externships.
So now we are all, collectively, called "the nursing staff", and referred to as "nurses"-by docs and management alike. They still hire a few LPN's and RN's, but the vast majority of our staff are comprised of MA's and UCLP-who call themselves nurses pretty much without exception. And the thing is, we all essentially perform the same duties. This means that RN's and LPN's do a lot of clerical work-pre-certs, coding, scribing, ordering supplies, and the like-in addition to clinical duties. This also means that MA's and UCLP's do a lot of nursing-everything from injections and wound care to assessments, patient teaching, and triage.
This seems wrong to me, on so many levels.
I do not begrudge the fact that I have to do office work, just to be clear. I know that the unfortunate reality of nursing in any setting is that documentation takes up a good chunk of your time. Where I start to have a problem is that I'm often stuck doing this type of work while a layperson with little or no formal training or education-who has at most taken a survey course on pharmacology-is put in charge of something like triage. With all due respect to MA's/UCLP, they aren't trained in this area and some of the decisions they make are downright dangerous. I have seen them tell patients to discontinue antibiotics because of an upset tummy, when that is a known side effect of the med and can be mitigated by taking it on a full stomach. I have seen them brush off patients with dypnea, obvious s/s of raging infection, possible internal bleeding, etc. and schedule them in next available instead of assessing them further and/or advising them to seek emergency care. I've seen a MA tell a mother of a child with a hx of reflux who was having difficulty swallowing her abx to sit on top of her child, hold her nose, and use a syringe to force it down her throat. These are just a few examples, and I've only been there for 3 months.
These people are not trained, not qualified, to assess a patient. It's obvious in most of their work. With a few exceptions, the documentation is garbage. I cringe when I read medical records and "nursing notes" full of errors, misspellings, laymen's terms and missing information. Imagine reading an official medical record that says "Pt had cut on arm. Bandage changed". Which arm? What part of that arm? What did the wound look like? What kind of "cut"? Was it healing appropriately?? In the HPI of the medical record "pt say her stomach hurt". What is the quality, duration, location of this pain she "say" she has? What does it rate on the pain scale? Has she taken anything? Does "pt" have a history of any condition or is she taking a medication that causes GI upset? Is she vomiting? Argh!
When this has come up with MA's I've talked to, they have said "we do the same thing, you guys are just paid more". This is a sore subject with them and there is a lot of resentment towards licensed nurses because of it. There is a lot of one-upmanship. Most of the MA's make it known that they can do "anything a nurse can do" and then some. Because they have a very vague scope of practice, they can in reality do much more than a nurse can in a lot of ways. Because they are working under the doctors license, they will pretty much do whatever the doctor asks them to. They will prescribe, for example. I'm not kidding. There is a MA I work with who routinely prescribes medications after talking to a patient over the phone without any input from the doc she works for, because she claims she has worked for her so long that she KNOWS what this doctor likes to prescribe for certain conditions. She doesn't want to waste the doctors time by passing it by her first, so she just eScribes it herself and signs as the doctor. This is just one example, of many, of how MA's and UCLP use their vague scope of practice-and the restriction of ours-to their "advantage", to make themselves appear more valuable.
The thing is, according to HR policy, there is a very specific job description for a MA, a LPN, and a RN. And they are supposed to be different. MA's are supposed to do office work and assist in data collection-i.e. taking vitals. They may give injections and administer meds under the doctors supervision. They may take information from the patient and relay it to the MD, and then tell the patient what the MD/NP advises. RN's and LPN's are supposed to assess, do phone triage, and do patient teaching. None of these duties are in the MA's job description, but that doesn't seem to matter. In every office I have worked, they do it anyways. Again and again, every single day, I see my profession undermined, devalued, and laughed off. And nobody seems to see an issue with this.
Some more examples of this at a management level
- For national nurses week, we got a free lunch and an umbrella. By we, I mean licensed nurses, MA's, and UCLP.
- Group emails from management are addressed to "attention nurses"
- Providers routinely refer to us as a collective as "our/my nurses". Aside from the misappropriation of the title, I find this paternalistic and creepy. We are also expected to do things like get coffee for the providers and tidy up their offices.
- During my employee orientation, our director of clinical quality first made it a point of how "_____ Clinic would be nothing without it's nurses. They are our backbone, the most trusted members of our team", and gave a moving speech about how nurses are the most trusted professionals according to U.S. News and world report surveys for the past x years...and then went on to say "it doesn't matter if you are a medical assistant or just someone that one of our doctors hired to take care of our patients, you are still a nurse, and that's what matters. Anyone can be a nurse"
Anyone is a nurse. Everyone is a nurse.
I'm so $)(*%$)( over this. I worked my a$$ off in nursing school, and then to pass my boards. My program was 18 months of grueling, intense work. I'm proud to be a LPN. I earned the title of "nurse", and I don't appreciate it being usurped and used by anyone who puts scrubs on in the morning. Maybe "anyone can be a nurse", but you have to actually go through the gauntlet of nursing school and passing the NCLEX to become one.
My boyfriend works in construction and made the point that NO ONE in his field would call themselves an architect unless they were licensed as one. NO ONE would call themselves an engineer. I wonder how the docs I work with would feel if I started calling our NP's "Doctor so and so"? Why is this tolerated in nursing? I know from reading about this topic here at AN that this is not an isolated issue and it happens all the time in our field.
I have spoken to quality management about it but nothing was ever done. I have spoken to other nurses about it, and a few of them agreed that it irked them but didn't want to make waves. We are outnumbered and because of the changeover few of us have seniority. Most of them said it didn't even bother them, which kind of blows my mind.
I have thought about leaving, but it took me 6 months to find this job and aside from this BS I do love it, and frankly I need it to support my family. I'm going back to school so I have more options, but for a LPN in my area it's pretty slim pickings. So should I just let this go? Or what, if anything, can I do about this?
Ruby Vee, BSN
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