Medication Aides: Regulations, Safety, & Practice

Jill Budden, PhD

Introduction

Part I: Medication Aide safety and practice: A review of

the literature

Part II: State-by-state review of Medication Aide

regulations

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

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

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

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

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

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

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)

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

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”

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

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

Exploring Regulations:state/jurisdiction breakdowns

Titles for Unlicensed Assistive Personnel that Administer Medications

Frequency

Percentage of states with UAPs that administer

medications using title

(n = 34)

“Medication Aide” 27 79%

“Medication Assistant” 9 26%

“Unlicensed Personnel” 5 15%

“Medication Technician” 4 12%

“Medication Administrative Personnel”

13%

Facilities that Utilize Unlicensed Assistive Personnel that Administer Medications

FrequencyPercentage of jurisdictions

(n = 46)

Nursing Home/Skilled Nursing Facilities 18 39%

Assisted Living Facilities 17 37%

Intermediate Care Facility/Mental Retardation 9 20%

Long Term Care Facilities 8 17%

Residential Care Facilities 7 15%

Adult Care Homes/Adult Foster Care 5 11%

Correctional Facilities 4 9%

Facilities for the Developmentally Disabled 3 7%

Mental Health Facilities 3 7%

Schools 3 7%

Group Homes 2 4%

Juvenile Facilities 2 4%

MISSING 3 7%

Length of Time Medication Aides have been Practicing in Nursing Homes

n M SD Min Max Median

Years 3115 years, 5 months

11 years, 5 months

9 months 45 years 12 years

Exploring Regulations: regulatory oversight

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

Exploring Regulations:applicant requirements

CNA Not Required

(35%)

Missing (15%)

CNA Required

(50%)

Percentage of Jurisdictions Requiring CNA Status Prior to Training

CNA Experience Requirements

FrequencyPercentage of jurisdictions

(n = 46)

CNA work experience requirements 15 33%

Not applicable (CNA not required) 9 20%

Not required to be a CNA, but have work experience requirements

6 13%

Not specified 9 20%

MISSING 7 15%

Exploring Regulations:training

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

Did not follow

curriculum (62%)

Missing (20%)

Followed curriculum

(9%)

Somewhat followed

curriculum (7%)

Uncertain (2%)

Total Hours of Training Required

n M SD Min Max Median

Training hours 34 73.97 40.60 4 150 72

Hours of Didactic Training Required

n M SD Min Max Median

Training hours 30 55.97 36.47 4.00 150.00 54.00

Hours of Clinical Training Required

n M SD Min Max Median

Training hours 30 22.20 14.86 0.00 40.00 20.50

Time Frame Training Must be Completed (not all data reported)

Frequency

Percentage of

jurisdictions(n = 46)

Not specified 11 24%

Determined by training program 4 9%

From 3 to 15 weeks 2 4%

The clinical portion must be completed within 6 months of the theory portion.

2 4%

1 day a week for 6 to 10 weeks 1 2%

1 to 2 weeks 1 2%

14 days for theory, 30 days for clinical, for a total of 44 days

1 2%

Percentage of Jurisdictions with Some Form of Training Exception

Training exception

(42%)

No training exception

(28%)

Missing (26%)

Not applicable (no training

required) (2%)

Not specified

(2%)

Percentage of Jurisdictions with Training Exception if Education from Another State is Substantially Similar

FrequencyPercentage of jurisdictions

(n = 46)

No 10 22%

Yes 9 20%

Not specified 1 2%

Not applicable (no training required or no training exception)

14 30%

MISSING 12 26%

Percentage of Jurisdictions with Training Exception if Pass Exam

FrequencyPercentage of jurisdictions

(n = 46)

No 5 11%

Yes 14 30%

Not specified 1 2%

Not applicable (no training required or no training exception)

14 30%

MISSING 12 26%

Percentage of Jurisdictions with Training Exception if Applicant has Some form of Work Experience

FrequencyPercentage of jurisdictions

(n = 46)

No 18 39%

Yes 1 2%

Not specified 1 2%

Not applicable (no training required or no training exception)

14 30%

MISSING 12 26%

Percentage of Jurisdictions with Training Exception if Applicant has Some form of Nursing Education

Frequency

Percentage of

jurisdictions(n = 46)

No 9 20%

Yes 10 22%

Not specified 1 2%

Not applicable (no training required or no training exception)

14 30%

MISSING 12 26%

Percentage of Jurisdictions that have Training Locations in Facilities

Frequency

Percentage of

jurisdictions(n = 46)

Yes 18 39%

No 14 30%

Not defined 1 2%

Not enough information given 2 4%

Unknown 1 2%

Not applicable (no training required)

1 2%

MISSING 9 20%

Percentage of Jurisdictions that have Training Locations in Education Institutions

Frequency

Percentage of

jurisdictions(n = 46)

Yes – training in education institutions

28 61%

No – no training in education institutions

5 11%

Not defined 1 2%

Not enough information given 1 2%

Unknown 1 2%

Not applicable (no training required) 1 2%

MISSING 9 20%

Exploring Regulations:testing

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)

Test Administered After Training has Been Completed

Frequency

Percentage of

jurisdictions(n = 46)

Yes (written) 23 50%

Yes (written & manual) 12 26%

No 2 4%

No – tests are a part of training 2 4%

Yes (written or oral & manual) 1 2%

Determined by education program 1 2%

MISSING 5 11%

Pass Rates for the Written Exam

n M SD Min Max Median

Pass rates (written) 11 .73 .17 .40 .94 .80

Pass Rates for the Written Exam

FrequencyPercentage of jurisdictions

(n = 46)

Not public information 1 2%

Not tracked 8 17%

Unknown 5 11%

Not applicable (no written exam) 4 9%

MISSING 17 37%

Passing Score for the Written Exam

n M SD Min Max Median

Passing score (written) 32 .77 .07 .70 .90 .80

Passing Score for the Written Exam

FrequencyPercentage of jurisdictions

(n = 46)

Determined by education program 1 2%

Not Applicable (no written exam) 4 9%

MISSING 9 20%

Passing Score for the Manual Exam

FrequencyPercentage of jurisdictions

(n = 46)

100% 5 11%

80% with no critical items missed 1 2%

Determined by education program 1 2%

Not applicable (no manual exam) 23 50%

MISSING 16 35%

Number of Times Individuals are Allowed to Take Exam

n M SD Min Max Median

Times allowed to take exam

28 2.36 .56 1.00 3.00 2.00

Number of Times Individuals are Allowed to Take Exam

FrequencyPercentage of jurisdictions

(n = 46)

1 time 1 2%

2 times 16 35%

3 times 11 24%

No limit 3 7%

Determined by education program 1 2%

Not applicable (no exam) 4 9%

MISSING 10 22%

Time Frame Individuals are Allowed to Take and Retake Exam (subset of data)

FrequencyPercentage of jurisdictions

(n = 46)

Within 30 days 1 2%

Within 60 days of training completion 1 2%

2nd exam completed within 45 days from failure notification

3 7%

Retake within 90 days 3 7%

Within 3 months of training completion 1 2%

Within 6 months of training completion 4 9%

Within 1 year of classroom training completion 1 2%

Within 1 year of training completion 1 2%

Within 1 year from the date of application 1 2%

Within 12 months after the first day of training 1 2%

Are Individuals Allowed to Retake Training then Retake the Exam?

FrequencyPercentage of jurisdictions

(n = 46)

Yes 18 39%

Candidates who fail will be withdrawn from the program

1 2%

Determined by education program 1 2%

Not applicable (no exam) 4 9%

MISSING 22 48%

Exploring Regulations:supervision and continuing education

Supervision:A licensed health car professionalA licensed nurse or physicianA licensed nurseRN charge Nurse or LPN charge nurseA licensed nurse who is physically present on the

same unitThe delegating nurseA licensed nurse on duty or on callPrescriber or RNsThe facility manager/administrator

Continuing Education Requirements and Time Frames (subset of data)

Frequency

Percentage of

jurisdictions(n = 46)

None 9 20%

8 hours, every 2 years 3 7%

7 clock hours, every 1 year 3 7%

6 hours, every 1 year 2 4%

10 hours, every 2 years 2 4%

Competency assessment, every 2 years 2 4%

Clinical update, every 2 years 2 4%

16 clock hours, every 2 years 1 2%

12 hours, every 1 year 1 2%

8 of 24 hours medication related, every 2 years 1 2%

Retraining, every 2 years 1 2%

Exploring Medication Aide Limitations to Practice by Jurisdiction

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.

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

Jurisdiction 3

Do not: Convert drug dosages Administer injectable medications (including medications

via subcutaneous, intradermal, intramuscular, or itnravenous routes)

Administer medications via tubes inserted into any body cavity

Administer antineoplastic drugs Accept verbal/phone orders from those with prescriptive

authority Dispense medications for residents temporarily out of the

facility

Discussion

Variations in training, testing, and practice, intuitively suggest that some Medication Aide program models result in better safety outcomes versus others.

Should be a push for more uniformity in training, testing, and practice.

A more consistent Medication Aide model may result in more assurance in the general safety and practice of Medication Aides.