To: Ohio Board of Nursing
From: Paul M. Dohse, STNA, MA-C, LPN
Subject: MA-C Reciprocity
Greetings,
I am writing to you regarding the proposal to add 4723-27-11 to the Ohio Administration Code. This letter will state my concerns for the following reasons: MA-C reciprocity will increase staff shortages, medication errors, and will exacerbate the core problem that reciprocity seeks to address. Therefore, this letter will also include suggestions or ideas that could yield positive outcomes for the new rules. My perspective will include experience working as a MA-C for two years, and then recently becoming a fulltime LPN in a long-term care facility.
A primary concern for the OBN is that nurses operate within their scope of practice. However, the other side of the coin follows: quality of care depends on the ability of nurses to function according to their full scope of practice. It is understood that a limited scope of intended practice will lead to neglect of care. Furthermore, though the nursing scope of practice is dominated by medication administration, inevitable attempts to achieve the full scope will lead to undue stress, job burnout, excessive hours worked, and medication errors caused by distractions and mental fatigue.
This is where a conflict exists between the purpose of a MA-C, and the purpose for the proposal. It is fairly evident that the discipline of Medication Aide Certified, as implied by the title, is intended to prevent nursing practice from being dominated by medication administration, and thereby severely limiting the intended scope of nursing practice. This limited scope of practice stands alone as the central cause for the severe nursing shortage in Ohio long-term care facilities.
The new proposal prompted by the Ohio Common Sense Initiative[i] and SB 131[ii] seeks to eliminate the obstacle of obtaining another license or certification to practice in another state other than the state where licensure or certification was obtained. Especially in healthcare, you do not want to create obstacles for those who relocate to another state. At the very least, this would delay their ability to practice after relocation, and would, at least temporarily, remove those people from healthcare staffing. With that said, there is a healthcare staffing shortage in all states; therefore, reciprocity only rearranges the overall shortage to varying degrees and does not address the core problem. Nevertheless, discussion surrounding the proposal offers a possibility to begin substantive changes that will improve staffing shortages and quality of care as opposed to making those situations worse.
It would seem that the nursing community refuses to learn from the past. Nurse reciprocity has done nothing to solve staffing problems, so it begs the question, why would MA-C reciprocity yield a different result? Somehow, it is thought that exchanging nurses and medication aides between 50 failed state systems will solve a common problem. In Indiana, where medication aides are thriving and have been used since 1977[iii], a substantial nurse shortage exists.[iv] Why then, would medication aides coming from Indiana to Ohio solve a nursing shortage in Ohio?
Also, from its conception in 2009[v], Ohio nurses have utterly rejected the MA-C program and the concept in general. Only recently, in 2021, have MA-Cs been used on any significant level. Why is this? It is because MA-Cs are not used according to their intended purpose. This is nothing new. In a similar way, Ohio state-tested nurse aides are not used according to their full scope of practice resulting in a failure to give nurses some measure of relief. In Ohio, the working relationship between nurses and STNAs is abysmal leading to staff shortages in both disciplines. STNAs are only expected to perform a fraction of their training resulting in stripping the position of its dignity, while robbing nurses of needed assistance.
Regarding MA-Cs, instead of using them to aid nurses, they are used as an ill-advised attempt to solve staffing shortages by replacing nurses. In addition, this is also seen as a way to reduce cost, which few would object to. Regarding the first use of MA-Cs, this will increase the workload of remaining nurses, leading to compounded stress, staff turnover, and an even deeper resentment of the MA-C discipline by licensed Ohio nurses.
By way of example, let us look at a LTC facility with two units. First, we will examine the approach that replaces one nurse. In this example, we have a nurse on one unit and a MA-C on the other unit. This scenario greatly increases the workload of the one nurse. The nurse, in addition to passing her/his schedule 2 drugs, must pass those drugs on the other unit, administer the insulin for both units, and do all nurse charting for both units as well as processing new orders. Nurse pushback against the MA-C discipline in Ohio is not a result of fear in being replaced, but more about how MA-Cs are being utilized. If one reads the Ohio Common Sense Initiative and SB 131, the new proposal to make boards and agencies compliant boils down to replacing missing nurses with medication aides, which as illustrated above, compounds the very reasons that nurses are leaving the nursing profession in the first place. In addition, the replacement approach will place undue stress on the medication aides as well, leading away from an undivided focus that prevents medication errors.
There is a use of medication aides that will solve the problem. That is, as the nomenclature itself states, using medication aides to aid nurses rather than replace them. In the same example of two facility units, we have two medication aides, one on each unit, and one nurse overseeing all aides, administering schedule 2 drugs, insulin, treatments, charting, taking calls from family members, and processing orders. In other words, performing the full scope of practice needed for the delivery of quality care. This will lead to an increase in nurses due to the ability to perform what they love to do. The cost might be slightly more than two nurses but will result in an increased census due to the quality of care, and the elimination of agency nurses to replace staffing shortfalls. Invariably, MA-C reciprocity will lead to the vast majority of medication aides in Ohio being employed by agencies, and thereby increasing cost, while resulting in an increased shortage of nurses. Indeed, agencies are advertising the aforementioned benefits[vi], but experience teaches us that the selling points are pretense and at a much greater financial cost. This is why medication aide programs in all other states have not made any measurable difference in nurse staffing shortages; namely, a misguided application of the discipline.
Unfortunately, the present shortage of nurses in Ohio is a completely unnecessary problem defined by a lack of education and vision concerning the aide concept and its relationship to nurses, whether nurse aides or medication aides. Though much could be said about nurse aides and their proper relationship to nurses, which is woefully inept in Ohio, and has all but destroyed the spectrum of best practice, the MA-C program does offer a contribution to nurse aides in the form of upward mobility.[vii] This also speaks to the very important concept of hiring within, which is essential to retaining staff and reducing turnover. But, reciprocity will also remove this necessary element from the process of curing staff shortages and subsequent lack of care. It all begins with neglecting nurses via lack of vision concerning nurse aides, and the misappropriation of medication aides to replace nurses rather than aide them in practicing what they are trained to do and love to do. It all begins there, and results in a vicious downward spiral primarily affecting those awaiting the care they are rightfully due.
Confusion concerning regulation of medication aides from state to state could be added here[viii] along with many other arguments concerning MA-C reciprocity, but it is understood that reciprocity is now a matter of compliance to Ohio law. With that said, there is ample opportunity to mend the misguided law with rules that will invoke substantive education and proper application. Reciprocity will solve nothing and only make the problem worse, but the opportunity to invoke new rules will improve the problem and set examples for other states. For example, there is a rule concerning Ohio MA-C that follows: a MA-C cannot accept two assignments as an aide and medication aide. Presumably, this rule is to prevent distractions while passing medications. Like rules could be instituted that address the concerns of this letter.
In conclusion, the new rules must foster aid to nurses, not the replacement of those missing. There are no substitutions for nurses that will result in best practice.
Respectfully,
Paul M. Dohse Sr., STNA, MA-C, LPN
[i] Ohio Commonsense Initiative. (n.d.). Register of Ohio. https://www.registerofohio.state.oh.us/servlet/RooBusinessPDF?ruleActionId=591488&docTypeId=14
[ii] SB 131. (n.d.). https://search-prod.lis.state.oh.us/solarapi/v1/general_assembly_134/bills/sb131/EN/05/sb131_05_EN?format=pdf
[iii] https://www.nursingworld.org/~4af4e6/globalassets/docs/ana/ethics/state-chart-medication-aide-status-09-15.pdf
[iv] https://www.indystar.com/story/opinion/2022/10/27/nurse-indiana-nursing-shortage-fixing-issues-salary-edcuation-mental-health/69589885007/
[v] Ohio Nurse. (n.d.). Medication Aides–What the Laws and Rules Say. https://media.healthecareers.com/wp-content/uploads/2022/07/27174714/OH9_10.pdf
[vi] Admin, L. (2018, 4). Ohio medication aide certification program. LeaderStat: Healthcare Recruiters & Consultants. https://www.leaderstat.com/knowledge-base/ohio-medication-aide-certification-program
[vii] Grebbin, S. (2023, April 19). ‘Creative staffing’: Nursing homes push to allow CNAs to administer medication citing labor benefits, savings. Skilled Nursing News. https://skillednursingnews.com/2023/04/creative-staffing-nursing-homes-push-to-allow-cnas-to-administer-medication-citing-labor-benefits-savings/
[viii] Ohio Nurse page 5. https://media.healthecareers.com/wp-content/uploads/2022/07/27174714/OH9_10.pdf
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