Medication Aides: Regulations, Safety, & Practice

1. Medication Aides: Regulations, Safety, & Practice Jill Budden, PhD

2. Introduction • Part I: • Medication Aide safety and practice: A review of the literature • Part II: • State-by-state review of Medication Aide regulations

3. PART I: Literature Review • The Medication Aide role • Medication Aide program implementation • Medication Aide medication management policies • Characteristics of facilities using Medication Aides • Medication Aide medication administration processes • Delegation to Medication Aides • Medication Aide & licensed nurses job satisfaction and stress • Medication Aide medication error rates

4. The Medication Aide Role • May drastically vary both between and within states: • job descriptions • training • testing • supervision • Job analysis (NCSBN, 2007) • Concerns and uncertainty surround the role (Quallich, 2005) • Future research: • standard job description • core competencies

5. Medication Aide Program Implementation • Unique set of challenges: (Randolph, 2008) • personnel shortages • curriculum rigors • licensed nurses’ initial resistance • Potential benefits: (Randolph, 2008) • freeing nurse time • staff satisfaction • increased ability to meet residents’ care needs • NCSBN’s Medication Assistant model curriculum (Spector & Doherty, 2007; NCSBN, 2007) • Future research: • indepth investigations on program aspects • Ex: amount/type of training, testing, and supervision

6. Medication Aide Medication Management Policies • No evidence of harm to patients receiving nurse delegation in Washington State (Young et al., 1998; Young & Sikma, 1999) • Nurse delegation enhanced the quality and intensity of supervision in Washington State (Young et al., 1998; Young & Sikma, 1999) • Case study of policy application (Sikma & Young, 2003) • Lack of clarity in practice parameters may result in confusion and procedures that “push the envelope” (Reinhard, et al., 2003; 2006) • however, no evidence of harm related to med admin • Future research • the effects of specific state or facility policies on outcomes

7. Characteristics of Facilities Using Medication Aides • Only 1 study (Hughes, Wright, & Lapane, 2006) • Homes that utilized Medication Technicians: • “substitution” style of working • fewer CNAs and RN/LPNs per 100 beds • more deficiency citations related to med errors • questionable supervision • Future research • more rigorous comparisons of facilities that do versus do not utilize Medication Aides

8. Medication Aide Medication Administration Processes • Vary widely from facility-to-facility and from state-to-state. • Subtle differences between “assisting” versus “administering” (Mitty, 2009) • Outline of the top areas in which Med Aides need additional training (Center for Excellence in Assisted Living, 2008) • Difficult to provide timely med admin to large groups of residents & communication related to administration and monitoring was the core of many problems (Vogelsmeier et al., 2007) • Future research • In-depth investigation of communication related to medication administration and monitoring

9. Delegation to Medication Aides • Assessment, evaluation, and judgment cannot be delegated – yet medication administration by UAPs often requires assessment and judgment (Mitty & flores, 2007) • Administration errors were detected in 20% of doses and almost all errors (99%) occurred during preparation or recording rather than final administration (Dickens, Stubbs, & haw, 2008) • Future research • Nurse delegation of medication management activities and resident outcomes (Munroe, 2003) • Kind and quality of education, training, and monitoring for the safety of UAP practice and on errors and adverse outcomes (Mitty & Flores, 2007)

10. Medication Aide and Licensed Nurse Job Satisfaction and Stress • Medication Nursing Assistant role enhances nursing care and decrease stress among nurses in long-term care facilities (Walker, 2008) • Future research • A study with a large sample with a quantitative survey design

11. Medication Aide Medication Error Rates • Arguably, the most important aspect • right drug, dose, client, time, route, & documentation • No significant difference in errors by level of credential (Scott-Cawiezell, et al., 2007) • UAP risks appear to be minimal & generally do well with med admin given level of preparation (Young, et al., 2008) • Of 99 Cefepime administrations, 80% were incorrectly administered (Hoefel & Lautert, 2006) • Future research • studies with sufficient group sample sizes • control for the medication administration “job”

12. Discussion • Studies not cohesive • Numerous limitations • Difficult to draw broad, generalizable, conclusions given wide variations in testing, practice, and supervision between and within states • In general, studies mostly supported Medication Aides’ safety of practice • Regardless of an article’s direction of support for Med Aides – recommendations for safety and practice were evident throughout

13. Part II: State-by-State Review of Medication Aide Regulations • Exploring characteristics of Medication Aide program regulations • State/jurisdiction breakdowns • Regulatory oversight • Applicant requirements • Training • Testing • Continuing education and supervision • Exploring Medication Aide limitations to practice by jurisdiction

14. Exploring Regulations:state/jurisdiction breakdowns

19. Exploring Regulations: regulatory oversight

20. Of the agencies that provide regulatory oversight: • 43% (n = 20) are the Board of Nursing • 44% (n = 21) are some other state department (e.g., Department of Health) • 8% (n = 4) are some combination of the Board of Nursing and some other state department

21. Exploring Regulations:applicant requirements

22. Percentage of Jurisdictions Requiring CNA Status Prior to Training

24. Exploring Regulations:training

25. Percentage of jurisdictions that followed NCSBN’s Medication Assistant Certified (MA-C) Model Curriculum

29. Percentage of Jurisdictions with Some Form of Training Exception

36. Exploring Regulations:testing

37. Wide variations in design and administration of the exam: • Board of nursing (design) • Department of health (design) • The training program (design & admin) • Committee (design) • Instructors (admin) • D&S Diversified Technologies • Comira testing • Pearson Vue • Psychology Services Incorporated • Professional Healthcare Development (PHD)

45. Exploring Regulations:supervision and continuing education

46. Supervision: • A licensed health car professional • A licensed nurse or physician • A licensed nurse • RN charge Nurse or LPN charge nurse • A licensed nurse who is physically present on the same unit • The delegating nurse • A licensed nurse on duty or on call • Prescriber or RNs • The facility manager/administrator

48. Exploring Medication Aide Limitations to Practice by Jurisdiction

49. Jurisdiction 1 • Shall not: • Receive, have access to, or administer any controlled substance. • Administer parenteral, enteral, or injectable medications. • Administer any substances by nasogastric or gastrostomy tubes. • Calculate drug dosages. • Destroy medication. • Receive orders, either in writing or verbally, for new or changed medications. • Transcribe orders from the medication record. • Order initial medications. • Evaluate medication error reports. • Perform treatments. • Conduct patient assessments or evaluations. • Engage in patient teaching activities.

50. Jurisdiction 2 • May not administer: • Parenteral or injectable medications • Initial dose or non-routine medications when the patient’s response is not predictable • When the patient’s condition is unstable or the patient has changing nursing needs • If the supervising nurse is unavailable to: • Monitor the progress of the patient • Monitor the effect of the medication on the patient • A nurse’s assessment of the patient prior to or following the medication is required • Calculation of dosage or conversion of dosage is required