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If someone turned patient care into a card game, unlicensed assistive personnel (UAP) would be the wild card. If you use them wisely, you can save your hospital money, free up nurses for more important responsibilities, and spread fewer professional people among more patients.
But without the proper attention, critics say, UAPs can lower your quality of care, cost you more than they save you, and could even endanger patients.
The debate over UAPs has been swirling since their ubiquitous use began spiraling upward as the pressure to reduce hospital costs increased. While some ICU managers have adopted a "learn to live with them" approach, others are still asking sharp questions about the encroachment of UAPs into nursing duties.
An American Nursing Journal study based on a survey of 7,355 RNs found that almost 42% of respondents reported that UAPs were being substituted for RNs.1 That concerns Judith Shindul-Rothschild, PhD, RN, CS, lead author of the study and assistant professor in the Boston College School of Nursing in Chestnut Hill, MA.
"There is clear evidence that if you cut back the number of RNs, more patients will end up with bedsores, more patients will have medication errors, and more patients will be injured by slips and falls, more patients will have more complications nosocomial infections being the big one."
But she is quick to caution that setting aside intuitive feelings and reports from the field there is little in the way of direct quantifiable evidence that UAPs are, overall, bad for the business of patient care.
"It’s clear that if you cut back on the number of RNs, patients will be harmed. It’s not clear in an empirical way that patients will be harmed if you substitute UAPs for RNs," she says.
"We have an abundance of anecdotal evidence that there is harm, but studies are just now under way on that. But that’s hard to do, and I’m not sure we’ll ever have the pristine data on that issue."
A major part of the struggle and controversy over using UAPs is determining what they can and cannot do. "There’s tremendous variance in the kinds of nursing responsibilities that are being delegated to UAPs and conditions under which they’re being delegated," says Shindul-Rothschild. "Pretty much everyone agrees that something like medications shouldn’t be delegated to a UAP, but you would be shocked about what I consider very invasive procedures being delegated to UAPs, whether it be catheterizations, inserting IV lines, G-tubes, or external dressing changes. It’s remarkable that this sort of experiment with patients and I do consider it an experiment is going on."
The rules established by nursing boards in each state provide some general guidance for what UAPs can and can’t do, but otherwise there is no guiding national standard. However, some help is available from the Aliso Viejo, CA-based American Association of Critical Care Nurses (AACN), which has developed a Competency-based Skill Building Curriculum for Unlicensed Assistive Personnel.
This 350-page document is divided into 21 modules with a bibliography. It includes the UAP survey results and accompanying discussion. A section designed for instructors covers the basic assumptions of the course, as well as a section of suggested teaching formats, teaching schedule, administering evaluations, and general recommendations. Each module contains the following:
• a teaching plan, including objectives, learning activities, key terms, and equipment;
• teaching aids, which may be used as handouts or overhead transparencies;
• performance checklist (see sample checklist, p. 27);
• a post-test.
The modules cover a wide range of topics, including basic foundation material on the role of UAPs, communication, and ethical and legal issues; sections on admission, transfer, and discharge; and bed making and patient hygiene, as well as detailed modules on the various body systems.
Though the modules have been organized in an order which presents basic material first, each module can be used independently. Also, modules can be combined with more extensive or customized material generated by the hospital.
The AACN curriculum isn’t an endorsement of the use of UAPs, but rather an acknowledgement that they are now part of patient care, says Michelle Holecek, RN, MN, MBA, CCRN, clinical practice specialist with the AACN.
While major opposition still exists to replacing RNs with UAPs, unlicensed assistants are finding more acceptance in hospitals that have been able to clearly define how to use them effectively, Holecek says. "What we’re hearing is that it is settling down somewhat because some boundaries that have been defined, and the roles and responsibilities are being more clearly identified."
She also notes that nurses are becoming better at delegating responsibilities. Under traditional models, nurses have done everything from administering medications to performing menial tasks. "It’s been quite an adjustment for nurses who weren’t used to a team model to master delegation skills," says Holecek. "That’s becoming less of an issue because nurses are more familiar with how that is integrated into clinical practice."
She emphasizes that the AACN curriculum isn’t a model that hospitals can use to create an effective UAP program. It’s still up to each hospital to figure out what works best. That can depend on your patient population, census, skill mix, existence of step-down units, and support systems offered by your hospital, she says.
To hurdle that barrier, Holecek suggests ICU managers talk with colleagues who have tried it. "Network with each other, look at [various] models, and do some trials of different models to see what combination works best," she says. Some institutions are becoming very innovative in developing hybrid models using, for instance, UAPs, licensed practical nurses, and even respiratory therapists. (For a study of how one hospital increased RN bedside time by expanding the duties of secretaries, see story, below right.)
Both Holecek and Shindul-Rothschild caution against basing your decisions on using UAPs strictly on finances. At one point in the mid 1980s, there were actually more unlicensed personnel than nurses, says Shindul-Rothschild. "But research showed that UAPs are the most expensive position in the nursing department. They stay on the job an average of 18 months vs. eight years for nurses, so you have to spend more on recruitment, training, supervision, and disciplinary action." The current trend to expand use of UAPs "is just a repackaged model of a work redesign that failed us in the mid 1980s."
Even if there are immediate cost benefits, be careful that the real price isn’t worse patient care and perhaps high patient care costs in the long term, she adds. "For one thing, these people are just not sophisticated enough to recognize the subtle changes in a patient’s condition. For another, they’re not trained as professionals who can collaborate with me on equal footing. Even if they do see something, they’re not assertive enough to call me and get me in there to do my own evaluation," says Shindul-Rothschild.
In an ideal world, nurse managers might be able to scuttle substitution of UAPs for RNs by vocally opposing them. But Shindul-Rothschild says her survey found that the downsizing of nursing staffs also applies to nurse managers. "We’re seeing nurse mangers spread very thin," she adds. "That makes it harder for them to be strong advocates. It’s a struggle for them to just get through the basics each day."
But if you decide to mount opposition, look for help from physicians, she advises. "The feedback I get from physicians concerned about the use of UAPs in hospitals comes almost exclusively from two areas: One is the OR, and the other is critical care. Physicians are vehemently opposed to substituting UAPs for RNs, and they’re looking for data to use with hospital administration to get rid of UAPs. But the data just aren’t there yet."
So what should an ICU manager do when told to cut unit costs? Look elsewhere, Shindul-Rothschild advises. "The waste is on the administrative side. I would encourage managers to look at [other areas] in the system to improve efficiencies. Start by asking the staff; do focus groups. Nurses have a lot of great ideas about how to save money, especially with supplies, and through use of computers. Let them do more documentation. Look for ways to get the nurses to stay at the patient’s bedside more. The problem I have with this model is that it pulls the most highly skilled, professionally prepared person, in terms of taking care of critically ill people, away from where they should be in that room taking care of that critically ill patient."
On this point, she speaks from personal experience. Shindul-Rothschild recalls a time when her father was in an intensive care unit and was being bathed by an RN. "The whole time she’s giving him a bath she’s also assessing his cardiac status. He’s not one to complain about pain, even if you ask him directly. It’s not until she’s turning him and sees the look on his face that she realizes that this guy’s in agony. In critical care, things like this make a huge difference."