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Should Supervisors Perform Bargaining Unit Work?

15 Jan

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By Mathew Keller RN JD, Regulatory and Policy Nursing Specialist

It’s happened to just about every RN at some point or another. Your unit is short staffed, and you’re doing the best you can — but you’re stretched too thin, and your patients aren’t getting the care they’re paying for and deserve. So you call your nurse manager. What happens?

Staff-nurse supportive nurse managers do their best to avoid these situations in the first place by staffing appropriately. However, sometimes it’s just not possible to prepare for unexpected events and changes in acuity. That’s why top nurse managers, when confronted with these situations, advocate for their units in order to get another bedside RN called in to lend a hand.

Some nurse managers may also offer to help out themselves. In limited circumstances, this may be acceptable. If the nurse manager is competent to perform the work, if there was no way the nurse manager could have anticipated the staffing needs in advance, and if the nurse manager is performing the work only in limited emergency circumstances, then MNA is unlikely to pursue a grievance for a supervisor performing bargaining unit work.[1] In such instances, the needs of our patients come first.

If, however, the nurse manager precipitated the staffing crisis through purposeful unsafe staffing, if the nurse manager is not competent to perform bedside RN care, or if there is a continuous pattern of unsafe staffing and supervisors performing bargaining unit work, then MNA can and will take action. As above, in such instances, the needs of our patients come first.[2]

A continuous pattern of supervisors performing bargaining unit work indicates a greater underlying problem—unsafe staffing. As Carrie Mortrud, RN, MNA Safe Patient Staffing Specialist, puts it:

We appreciate nurse managers who step up to the plate and help the team in emergency circumstances that could not have been anticipated. When nurse managers continuously do this, however, they are covering up a larger systemic and often chronic problem — unsafe staffing. They are putting a Band-Aid on an arterial bleed. Clearly a tourniquet is needed — with a temporary Band-Aid.

In those instances, nurse managers need to step up to the plate in another way: by staffing appropriately and hiring more nurses. This protects our licenses, our jobs, and more importantly, our patients.”

Are you experiencing a situation where your nurse manager is continuously performing bargaining unit work? We want to know!  Please let your steward, labor representative, or MNA’s Regulatory and Policy Nursing Specialist Mathew Keller know right away.

 


 

[1] See, for example, Essentia Health Virginia Contract p. 4: “Except in cases of emergency (an unplanned immediate need) or an unavoidable situation where patients would be deprived of needed nursing care, non-bargaining unit personnel shall not be used to perform bargaining unit work.”

[2] Please note that, in rare instances, smaller hospitals have negotiated language allowing supervisors to perform bargaining unit work.  See, for example, Deer River Contract Article 3.1: “Due to the relatively small number of RNs employed at the HealthCare Center and the relatively small size of the facility, the HealthCare Center has working managers who perform bargaining unit work in addition to their management duties.  Any significant expansion of managers doing bargaining unit work beyond that typically done at present shall be open to negotiations between the parties.  The minimum staffing for acute care at the facility will include two bargaining unit RNs if one RN is ER capable and one RN is charge capable.”

Say ‘no’ to UAP charting requests

14 Dec

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By Mathew Keller RN JD, Regulatory and Policy Nursing Specialist

In a cost-saving move, when certain units at a Minnesota hospital are short staffed, managers are asking nurses to allow Unlicensed Assistive Personnel (UAP) to chart under the RN’s license.  This allows UAPs to care for patients autonomously without supervision and oversight from RNs.

Needless to say, this practice is incredibly dangerous for many reasons, three of which we will highlight here.

  1. UAPs simply do not have the training or expertise to independently care for patients without proper RN supervision (and chart accordingly).
  2. Charts are legal documents, and when others chart using your name and login, it is legally the same as if you completed that charting and said that you did the work being documented.
  3. All electronic medical records track patient lookups and history; therefore, if the UAP utilizing your chart is looking at other patients, there is a strong possibility of HIPAA violations.

Far from a cost-saving practice, allowing UAPs to chart under someone else’s license is dangerous for the UAP, for the patient, for the nurse, and for the facility.

It cannot be emphasized enough how incredibly dangerous this practice is.  In fact, we have seen nurses in other facilities be disciplined for failing to log off their medical record properly, therefore resulting in someone else charting (inadvertently) using the nurse’s login.

Have you been asked to allow another to chart under your license?  We need to know.  Please contact your steward, your labor rep, and me — at Mathew.keller@mnnurses.org.

 

Practice Alert: Should nurses be filling the Pyxis?

20 May

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By Mathew Keller RN JD, MNA Nurse Practice & Policy Specialist

In a cost-cutting move, many Minnesota hospitals are asking registered nurses to take on more pharmacy duties. Where there may have once been pharmacy staff available 24/7 to answer questions, compound pharmaceuticals, and dispense medications, many nurses are finding that such coverage is now limited to 9-5 with an outsourced pharmacist in another city (or state) available by telephone after hours to answer questions and certify prescriptions. This can lead to potentially dangerous situations for patients as well as nurses’ licenses when nurses are asked to dispense and/or compound medications in the absence of a pharmacist.

One disturbing trend we are tracking is nurses being asked to fill the Pyxis or other automatic dispensing machine on the overnight shift. Non-pharmacy staff filling a Pyxis is unacceptable pharmaceutical practice. Furthermore, it is outside the scope of RN practice.

Under state law, only pharmacists are legally qualified to dispense medications, although they may be assisted in the task by up to two pharmacy technicians at one time.[1] Dispensing is defined as “delivering one or more doses of a drug for subsequent administration to, or use by a patient.”[2] When a nurse fills a Pyxis or other automatic dispensing machine, that nurse is delivering doses of drugs for subsequent administration to a patient.

While nurses may legally administer medications, they may not legally dispense them. Filling a Pyxis is outside the scope of RN practice and can lead to discipline against one’s nursing license as well as charges of practicing pharmacy without a license. In addition to scope and licensure issues, a nurse who fills a Pyxis assumes legal liability for any and all errors or patient harm resulting from improper dispensation (e.g. putting the incorrect medication in a Pyxis drawer).

Another common issue involves nurses being asked to mix IV medications in the absence of pharmacy coverage. The propriety of this practice is situationally dependent: reconstituting medications is acceptable nursing practice; compounding medications is not. Compounding is defined as mixing, packaging, and labeling a drug for an identified individual patient’s use.[3] The determining factor in whether or not you are compounding medications is whether the medication is for immediate use or not.  If a medication is being mixed for immediate use, it is acceptable reconstitution.  If the medication is being mixed for storage and later use, it is unacceptable compounding.

Lastly, many nurses are being given pharmacy access for after-hours care.  Under Minnesota rules[4], after-hours nurse access to the pharmacy should fulfill the following guidelines:

  • Withdrawal of medications must be limited to “emergency” situations, interpreted broadly by the Board of Pharmacy to include any time a necessary medication is needed but unavailable;
  •  Only one designated RN on a given shift may have emergency access;
  • The standard of practice is that narcotic access is limited to a locked narcotic drawer with a small supply of available medications, not full access to the narcotics safe;
  • The designated RN must properly document medications removed from the pharmacy;
  • The designated RN should have proper training from the pharmacy staff in pharmacy policies and procedures, as well as specific training regarding after-hours access.

MNA has and will continue to work with the Minnesota Board of Pharmacy in order to ensure that our patients are protected through proper pharmaceutical and nursing practice. Have you been asked to fill a Pyxis or compound medications? Please let us know at Mathew.keller@mnnurses.org.

[1] MN Statute §151.01 Subd. 27 (2)
[2] MN Rule 6800.7100
[3] MN Statute §151.01 Subd. 35
[4] MN Rule 6800.7530

Proposed Law Would Revoke Licensure for Medication Errors

11 May

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By Mathew Keller, RN JD, MNA Nurse Practice & Policy Specialist

“Samuel’s Law,” under consideration in the South Carolina Senate, would require the South Carolina Board of Nursing to revoke a nurse’s license “upon the board’s finding that a licensed nurse misreads the physician’s order and overmedicates or undermedicates a patient.”

While the circumstances surrounding the introduction of Samuel’s Law, involving the fatal overmedication of a 7-year old, are tragic, the bill is an inappropriate response and does nothing to correct the systems-level failures that are often the basis of medication errors.

As a systemic review of 54 studies on medication errors puts it, since “nurses find themselves as the ‘last link in the drug therapy chain’ where an error can reach the patient, they have traditionally been blamed for errors. However, the reality is that the conditions within which the person responsible for the error works, as well as the strategic decisions of the organization with whom they are employed, are often the key determinants of error.”[1] 

Therefore, any law that purports to reduce the incidence of medication errors ought to focus on systems-level failures that can lead to medication errors, including inadequate communication pathways (e.g. illegible prescriptions, poor documentation, lack of transcription), problems with pharmaceutical supply and storage, unmanageable workload, availability and acuity of patients, staff fatigue and stress, and interruptions or distractions during drug administration.

Correcting or addressing the above issues, rather than punishing unintentional errors with the loss of one’s livelihood, will go a long way toward addressing the root cause of medication errors Samuel’s Law seeks to address.  It also fits with the model of “just culture,” widely accepted and adhered to in both the medical and aviation industries, which seeks to create an environment that encourages reporting mistakes so that precursors to errors can be understood and systems issues can be fixed.

As Lucian Leape, MD, member of the Quality of Health Care in America Committee at the Institute of Medicine and adjunct professor of the Harvard School of Public Health, said in testimony before Congress, “Approaches that focus on punishing individuals instead of changing systems provide strong incentives for people to report only those errors they cannot hide. Thus, a punitive approach shuts off the information that is needed to identify faulty systems and create safer ones. In a punitive system, no one learns from their mistakes.” (Leape, 2000).

Samuel’s Law, while well-intentioned, uses the wrong approach to prevent medication errors.  How would you change the language to better prevent errors?  Share your thoughts in our comment section below.

[1] Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Causes of Medication Administration Errors in Hospitals: a Systematic Review of Quantitative and Qualitative Evidence. Drug Safety, 36(11), 1045–1067.