1. Alexander, Mary MA, RN, CRNI(R), CAE INS Chief Executive Officer Editor

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Two healthcare topics that are constantly being discussed are the nursing shortage and quality of care. Although separately each has its own specific discussion points, one can hardly discuss one without including the other. Added to these issues is the cost of today's healthcare. In an effort to address these concerns, some healthcare organizations are looking to other providers, such as respiratory and radiology technicians and Unlicensed Assistive Personnel (UAPs) to provide infusion-related services that historically have been administered by licensed professional nurses. With variations in education, licensing, and scope of practice, the organizations must consider any unintended consequences that can occur when others provide these services.

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UAPs-those healthcare workers who are not licensed to perform nursing tasks-have long contributed to successful outcomes in healthcare. They provide much-needed assistance to licensed nurses by helping patients with tasks such as bathing, ambulating, feeding, and taking vital signs. But changes in the healthcare environment, such as the nursing shortage and budget cuts, have caused many healthcare facilities to seek alternative ways to provide nursing care with more UAPs and fewer registered nurses.


Nurses have an obligation to ensure that high-quality, safe nursing care is delivered to their patients. With that obligation comes the responsibility to delegate tasks to unlicensed personnel that will ultimately help achieve the best outcomes for their patients. Historically, RNs have used their judgment to determine the jobs that UAPs could perform under their supervision, on a case-by-case basis. After assessing a patient's needs, the licensed nurse, who is legally responsible for the performance of the UAP, delegates tasks in accordance with the UAP's training and experience. In recent years, however, this compact has been breached by healthcare administrators who are redefining nursing care in the interest of the bottom line.


Licensed nursing professionals have specialized knowledge, judgment, and skills that cannot be duplicated by a UAP. Infusion nurses are expert in placing catheters, yet our specialized nursing practice is in danger of being devalued because of a disturbing trend toward allowing UAPs to practice infusion therapy. More worrisome, of course, is that patients are not receiving the high-quality care to which they are entitled.


New rules by the Centers for Medicare and Medicaid Services (CMS) have targeted preventable medical mistakes and allow CMS to refuse to reimburse healthcare facilities for such errors. Why, then, would any facility choose to substitute UAPs for licensed nurses? The probability of catheter-related infections greatly increases when personnel placing catheters lack the appropriate education and skill of an infusion nurse. Patients risk serious infection and even death if infusion care is not delivered by competent providers.


While some healthcare organizations are looking to broaden the base of providers, others are redefining the roles of those in acute care settings. For instance, California's Kaiser Permanente is phasing out licensed vocational nurses (LVNs) as they see a rise in acute care patients requiring professional care that they believe is best given by the RN.


Heathcare consumer advocates are also making their voices heard on this issue. The Robert Wood Johnson Foundation and the AARP Foundation have joined forces to find solutions to the nursing shortage that will enhance the quality of patient care in this country. (For more information on this partnership, please turn to the IV P.U.M.P. column in this issue of the Journal.)


Typically, what is in the best interest of the patient is usually the best choice for the healthcare organization. As nurses, we need to be front and center with the strategies addressing the nursing shortage, because if we don't advocate for our own profession, others will take advantage. We nurses need to be the ones defining our practice.


Mary Alexander, MA, RN, CRNI(R), CAE INS Chief Executive Officer Editor


Journal of Infusion Nursing