ARIZONA STATE BOARD OF NURSING Janet Napolitano Joey Ridenour Governor Executive Director REPORT TO THE LEGISLATURE ARIZONA MEDICATION TECHNICIAN PILOT PROJECT DECEMBER 2008 ARIZONA STATE BOARD OF NURSING REPORT TO THE LEGISLATURE ARIZONA MEDICATION TECHNICIAN PILOT PROJECT by Pamela K. Randolph, RN MS AZBN Associate Director of Education and Evidence-Based Regulation 2 Janet Napolitano Joey Ridenour Governor Executive Director Arizona State Board of Nursing REPORT TO THE LEGISLATURE ARIZONA MEDICATION TECHNICIAN PILOT PROJECT As Authorized by HB 2256 TABLE OF CONTENTS Page Number Summary of the Project 4 Appendix A – List of Steering Committee Members.............................................................20 Appendix B – Sunrise Legislation Report 24 Appendix C – House Bill 2256 2004 39 Appendix D – Delegation of Medications to PSMT Protocols 42 Appendix E – Educational Guidelines for Facilities 45 Appendix F – Medication Administration for PSMTs Syllabus/Curriculum 50 Appendix G – PSMT Scope of Work 74 Appendix H – Guidelines for Pilot Facility Selection 78 Appendix I – Candidate Handbook 81 Appendix J – Instructors Training Course 89 Appendix K – Arizona PSMT Final Report by D&S Diversified Technologies 92 REPORT TO THE LEGISLATURE ARIZONA STATE BOARD OF NURSING ARIZONA MEDICATION TECHNICIAN PILOT PROJECT Introduction A sunrise report was filed in 2002 by the Arizona Association of Homes and Housing for the Aging and the Arizona Health Care Association requesting regulatory oversight of a two-year certified medication technician pilot study (Appendix B). The Joint committee of reference approved the pilot study concept outlined in the sunrise report, leading to the introduction and passage of legislation enacted for the pilot to be overseen by the Board of Nursing (Laws 2004 (2nd Reg. Session) Ch. 121) (Appendix C). This law authorized the Board to establish a pilot program “to determine the impact to patient health and safety of allowing nursing assistants…and acting as pilot study medication technicians to administer medications under educational requirements and conditions prescribed by the board (Laws 2004, Ch. 121, section A).” With funding secured from non-governmental sources, the pilot study involved 6 long-term care facilities throughout the state. As directed by the 2004 law, the Board submits this report concerning the pilot study authorized by Ch. 121. As discussed below, the pilot study produced positive results. Although the study included only a small number of participants, the results do suggest that when facilities have properly integrated medication technicians into the care delivery system, resident care improves because the work of the medication technicians frees up nurses to perform higher level tasks. The legislature enacted House Bill 2256 (2004) to determine the impact to patient health and safety when licensed nurses delegate medication administration to certified nursing assistants (CNAs) with additional education in medication administration. The 4 bill made the Board responsible for developing protocols, prescribing the education, overseeing the project and preparing this report to the legislature by December, 2008. The legislation limited the pilot study to no more than six facilities. It also incorporated patient safety-related measures including: prohibitions to keep facilities from requiring a nurse to delegate medication administration to medication technicians, prohibitions against medication technicians administering medications to unstable or sub-acute residents, prohibitions against a medication technician administering any medication by needle and other measures incorporated within the study. Steering Committee The Board formed a steering committee to oversee the project (Appendix A). Membership on the committee included stakeholders from long-term care facilities, the Arizona Board of Pharmacy, the Arizona Health Care Association, a professional association of skilled nursing facilities, the Arizona Association of Homes and Housing for the Aging, another professional association of residential facilities for the aged, the Arizona Nurses Association, the Southern Arizona Nursing Coalition, and nursing education. The Steering Committee developed protocols regarding which medications could be delegated to a medication assistant (Appendix D). In addition to the prohibitions in the legislation, the Board approved the recommendations that certain medications and tasks associated with medications could not be delegated to a medication technician. The Board based the decision on whether the task would require the skill of a licensed nurse and whether the task had an increased potential for harm to residents. Tasks that could not be delegated included: 5 • The first dose of a medication, • A medication requiring a complex mathematical conversion, • Inhalant medications, • Skin patches, • Vaginal medications, • Sublingual medications, • PRN or “as needed” medications with some exceptions for low risk medications. The Steering Committee then formed three subcommittees: Research, Education and Funding. The research subcommittee determined the research priorities and design of the Pilot Study. The funding subcommittee worked to secure funding to conduct the research. Finally, the education subcommittee developed course guidelines, curriculum, and a legally defensible competency exam. The Steering Committee reviewed all subcommittee actions and in turn, made recommendations to the Board for its approval. Research The Research Subcommittee and Steering Committee reviewed various indicators and approaches to research the safety of using medication technicians in order to compare patterns of medication errors before and six months after the use of medication technicians in selected facilities. The original sunrise legislation and HB 2256 identify safety of medication administration by medication technicians as the central issue to be explored by the Board. The Board also believed that participant satisfaction would be an important indicator of acceptance of the medication technician role. Therefore the pilot study was limited to these two indicators. The research subcommittee reviewed various 6 methods to measure medication error. The subcommittee recommended the Flynn and Barker Naïve Observation Method2, the method recognized as the most valid and reliable for measuring medication error rates in health care settings. Under this approach, an observer watches and records each medication pass and then compares what the resident received to the medication ordered in the resident’s chart with no knowledge of the resident’s prescribed medications and without reviewing the administration record (MAR) during the observation. The Board decided to measure satisfaction using structured interviews of pilot program participants including medication technicians, delegating nurses and directors of nursing. . Funding At the outset, special note should be made that Kathleen Collins Pagels, Executive Director of the Arizona Health Care Association, proved to be the key in terms of obtaining the funding for this project. Without her leadership and the Arizona Health Care Association’s support, the study could not have been accomplished. The Board estimated that the research cost of the Pilot Study would total approximately $90,000. The Arizona Health Care Association contributed $30,000 seed money to the pilot study. St. Luke’s Health Initiatives approved a grant proposal for an additional $30,000. When no other funding option became available, the Board used the fee authorization contained in HB 2256 and collected $5000 from each of the facilities participating in the pilot study. Education Education Subcommittee members consisted of RN, LPN and CNA educators. The subcommittee reviewed course requirements in 19 states that allow for the delivery 7 of medications by unlicensed persons under a licensed nurse’s delegation and supervision. The educational setting options considered by the subcommittee included community colleges or facilities participating in the Pilot Study. Given the small number of participating facilities and the possibility of diverse geographic locations, facilitybased training proved to be the most feasible model to adopt. The subcommittee designed a 100 hour medication technician course consisting of 45 hours of didactic instruction, 15 hours of skill lab, and 40 hours of supervised medication administration to residents. The subcommittee created course guidelines (Appendix E) and a curriculum (Appendix F). The curriculum consisted of basic pharmacology information and safe medication administration principles. Members of this subcommittee also wrote approximately 300 multiple-choice item for the state administered competency exam. The subcommittee also established a training program for all instructors. Scope of Work After the establishment of the curriculum, research, and funding mechanisms, the Board and the Arizona Health Care Association issued a “Scope of Work” (Appendix G) for a researcher to determine the impact to patient health and safety of allowing nursing assistants, who met requirements prescribed by the Board, to act as pilot study medication technicians and administer medications under specified conditions. In response to the Scope of Work, the Board hired D and S Diversified Technologies (DSDT), the current vendor for the Arizona certified nursing assistant exam, to conduct the research. In turn, DSDT hired Dr. Jill Scott-Cawiezell RN, Ph.D., a nationally recognized expert on medication delivery and error in long-term care facilities to serve as 8 a consultant. DSDT also developed a standardized competency exam with both written and manual-skills portions based on the approved curriculum. Site Selection The steering committee developed criteria to select up to six sites to implement the pilot program (Appendix H). All long-term care facilities were sent invitations to a public meeting on September 20, 2005 to learn more about the project and the criteria for selection including the deadlines and time-frames for gathering data and submitting this report. The Board received seven applications, and of these, the Board approved the six facilities recommended by the steering committee: • Shadow Mountain (Scottsdale), • Good Shepherd (Peoria), • Mountain View (Tucson), • Heritage Health Care (Globe), • Copper Mountain Inn (Globe), • Silver Ridge Village (Bullhead City). The Board conducted its first training session with instructors in March 2006 with additional training sessions conducted in 2007. Silver Ridge Village became the first facility to implement training in April of 2006. All facilities had conducted at least one training session by July 2007. One facility (Heritage Health Care) dropped out of the pilot because it was unable to utilize medication technicians by October 1, 2007. Board staff visited all facilities during training, which included a specific education program directed at all delegating nursing staff of the facility. 9 Testing With significant contribution from Board staff and the Education Subcommittee, DSDT developed an item pool for a written competency medication technician exam consisting of over 1200 items. The test pool contained 761 total active items with each exam consisting of 50 items distributed according to a Board approved test plan. The Education Subcommittee designed the test plan (Appendix I) based on time allotted in the curriculum for each topic and the importance of each topic in terms of patient safety. Other states that draw from the item pool include Arkansas, Oklahoma, Montana, and Ohio. DSDT also developed a skills competency exam, using check-off lists developed by the Education Subcommittee. Students in the pilot study received a limited number of chances to pass the test before being required to re-take the course. In total, 21 persons passed both the written and manual skills tests out of 32 total exam administrations. The skills exam proved less challenging than the written exam with 78% passing the skills exam on the first attempt and only 41% passing the written exam on the first attempt. All but one student passed the skills exam on the second attempt and 59% of students passed the written exam on the second attempt. Implementation by Facilities All six participating facilities sent representatives to a 2-day “Train the Trainer” session held on March 3-4, 2006 (Appendix I). The training sessions provided needed opportunities for participants in the pilot study to discuss the unique features of the project, reinforce teaching-learning principles, including test construction, and augment the textbook adopted by the Board. Twenty five persons attended at least one of the two 10 days with 17 persons attending both days. Evaluations were overwhelmingly positive for the training. Board staff visited all participating facilities during training, with five of the six facilities receiving two visits, one in the classroom portion, and one during the clinical practice. When visiting the training programs, the following observations were made: • Remedial instruction was needed to help students develop basic algebra skills needed to calculate simple divided dosages (e.g. if a tablet contains 250 mg of a drug, how many tablets would you give if the order were for 500 mg?). Facilities received direction about the need to screen for basic math ability but allowed students who failed testing to enter and continue in the program to encourage interest and participation. • Board staff discouraged facilities seeking to condense the program into consecutive 8-hour lecture/lab days. Program personnel stated that the students could only attend the classes if such a schedule were offered. • Nurses on the units, while initially skeptical, enthusiastically embraced the concept once implemented. They also appeared to be reassured by the Board’s presentation on “Delegation to Medication Technicians”. • Instructors stated that teaching the course benefited them and updated their knowledge of pharmacology Several facilities failed to implement the medication technician training within a year of attending the “Train the Trainer” course due to turnover of teaching personnel, lack of qualified CNAs, shortage of CNA coverage, and administrative changes at the facility. The Board offered an additional “Train the Trainer” session on March 1-2, 2007 and has 11 conducted additional informal training sessions as needed to train new teachers. All facilities implemented training by July 1, 2007. Extensive training sessions will not be necessary in the future as the Board anticipates that textbooks geared to the medication technician role in long-term care facilities will soon be released5, 6 and statutory and rule requirement for training will be well known. Additional training needs to enhance instruction will be addressed at the Board’s annual conference for CNA instructors. All steering committee participants recommended that the current 80% passing standard for the CNA written exam remain in effect until additional data supports a change in the standard. One DON of a long-term care facility reported that her students did not initially take the exam seriously until the first failure. Once they studied and retook the exam, most of them passed. One facility trained three persons, however only one person passed the exam and then left the facility before ever practicing as a medication technician. Unfortunately, the Board had to drop this facility (Heritage Health Care) from the project due to their inability to implement the role in time to collect postimplementation data. The Steering Committee invited all pilot study participants to attend all steering committee meetings and offer their perspective. Some common themes include: • Difficulty Recruiting CNAs for the Role. Many facilities found that attracting CNAs to the program presented more challenges than anticipated and that they needed to increase hourly wages and offer other incentives to gain participation. 12 • CNA Shortages. Even with an adequate number of CNAs trained and qualified for the role, shortages of CNAs in the facility necessitated that they work primarily as CNAs rather than as medication technicians. • Positive Acceptance of Delegation to Medication Technicians. Nurses delegating to CNAs reported very positive results and experiences. In some facilities additional CNAs became attracted to the role after observing their colleagues functioning as medication technicians. • Positive Impact on Medication Administration by Nurses. The medication technicians discovered and reported unsafe medication practices and RN/LPN medication errors. One facility changed its medication administration schedule in response to a medication technician’s concern that resident’s medications were inappropriately scheduled. The Board received a report, late in the project, that one of the participating facilities received a negative federal survey resulting in a sanction. A sanction prohibits the facility from conducting CNA training for two years (OBRA 87). The surveyors cited medication errors by both medication technicians and nurses but also found improper labeling by the pharmacist which contributed to the errors. One error involved a simple math miscalculation by the medication technician. Department of Health officials concluded that the sanction stemmed chiefly from a lack of evaluation for physical therapy services. Based on the recommendation of the steering committee, the Board decided to continue the facility’s participation in the project with monthly medication error audit reports to the Board. The facility submitted error-free reports, except for a 13 single report concerning a medication technician found to have a high error rate. After retraining, the technician had error-free reports. At present, a total of 21 qualified medication technicians continue to administer medications under the delegation of a licensed nurse in five long-term care facilities. Participating facilities want to continue to use medication technicians, but face the continuing challenge of CNA shortages, high staff turnover, and other fiscal constraints. Offering the program on a state-wide basis will solve some of the challenges that the participating facilities have faced. Further, a state-wide program may lead recognized educational institutions to participate in training with a resultant increase in training opportunities, higher passing rates on the competency exam and less reliance on facility staff for training. Research Results as Reported by D and S Diversified Technologies4 This section contains a summary of the report from the researcher, DSDT. The total report is found in Appendix K. Medication Error Rates Pre-implemetation mean medication error rate of 10.4% (LPN, 10.12%; RN, 11.54%) were obtained. These rates are not statistically or clinically different for RN and LPN levels of licensure. Post-implementation observation revealed a mean medication error rate of 6.6% (LPN, 7.25%; RN, 2.75%; Medication Technician, 6.06%). Again, there were no statistical or clinically significant differences noted among the medication administrators based on credential. There were no statistically significant differences in either rate or pattern of error before or after the utilization of medication technician. While it appears 14 that there was an actual lowering of the medication error rate, due to limited power of the study, the result is not considered significant. Staff Satisfaction Interviews of study participants from the five nursing homes after the post pilot study intervention data collection period allowed some insight into staff perceptions and acceptance of the project. Persons interviewed included Directors of Nursing (DONs), Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Pilot Study Medication Technician (PSMTs). The majority of respondents worked at least of 35 hours per week and ranged in experience from 1 to 23 years. All nurses interviewed indicated that despite some early misgivings about the new medication technician role, when they were able to partner with a PSMT, they had more time to work directly with the residents. These findings closely align with another study7 that provides empirical evidence supporting the medication technician role in reducing job stress and increasing satisfaction among licensed nurses. Nurses reported feeling better about their resident care and assessments (p. 4). ”The concept is fabulous, I now have more time to assess my residents and work with other staff. In the past, I felt stuck behind the med cart.” “…nurses are now more available.” “…it is hard when the techs aren’t here, they are good partners.” The medication technicians also reported that it was their perception that nurses were spending more time with residents. Medication technicians also were affected by the delegating nurse’s acceptance of the role. “I had a very difficult time in my new role at first. My nurse was constantly looking over my shoulder and making me very nervous. I could not get the pass done. Now, I have a new partner and I love what I am doing. We work really well together. “(p. 4-5) 15 One facility had a great deal of difficulty in securing adequate staffing to fully and consistently implement the medication technician role. Although nurses could see benefit from the addition of the role, they also reported frustration when medication technicians were not assigned as a partner. Medication technicians also functioned in additional roles along with their medication administration responsibilities. Some reported tailored shifts to maximize the medication administrations opportunities. All reported that they assisted other staff and residents when not administering medications. The informants clearly delineated the protocols regarding which medications could be passed by the medication technicians and which were the responsibility of the nurse. Nurses were sometimes challenged by the sharing of medication administration responsibility. However, it was reported that systems to track medications that require administration by a nurse (PRN narcotics, inhalers) were being developed and implemented. All informants, except one nurse who felt she pampered her residents, reported the residents were very happy with the addition of the medication technician role. “They miss her when she is gone, the resident keeps asking me where [she] is today.” “Residents are glad for the change; they don’t have to wait for their meds.”(p.5) Informants reported minimal changes to the medication administration procedure. Many informants reported they believed there were fewer medication errors and a noticeable improvement in timely delivery of medications. (p.5) Informants provided recommendations and lessons learned during the pilot medication technician project. The recommendations include: • The timeframe for the training was too condensed. The training needs to be more spread out to allow time to study the critical concepts. 16 • We need more medication technicians and they need to be consistently assigned to the role to improve and build systems. • Licensed staff would like to review the training so there can be consistent reinforcements for the medication technicians. The lessons learned include: • Speed comes with time, the key is being very careful. • I now understand why blood pressures are so important for the medication pass and I always double check them myself. Now I know why my nurse was always asking me what their blood pressure is. • PSMT add flexibility to staffing.” (p. 5-6) Conclusions Findings suggest that the introduction of medication technicians to the medication team in a long-term care facility will not negatively alter the rate or pattern of medication error. Significantly, an AHRQ funded medication safety study (Scott-Cawiezell et al., 20071; 20073) reached similar conclusions. In addition to the safety data presented, health care personnel consistently reported positive results with the addition of the medication technician to the healthcare team. In addition the study found no evidence that facilities replaced licensed nurses with medication technicians and no incidents of drug diversion by medication technicians. In short, the Arizona pilot study confirms earlier studies which indicate that medication technicians can provide safe medication delivery. However, the Board also recognizes that many factors remain to be addressed. Nursing home residents have many illnesses, take many medications, and therefore are vulnerable to subtle alterations in 17 their medication regimens. Many of the medications delivered in a routine medication administration do require assessment for potential adverse effects. CNAs and medication technicians lack assessment skills and knowledge to make adjustments or watch for many potential changes that a resident may undergo, including adverse drug effects. Thus, as recognized in the sunrise report and the enactment of HB 2256, the role of the licensed nurse remains critical to the management of the resident’s health and medications. As stated by DSDT in its report: “Nursing homes have many challenges in the midst of very fiscally constrained budgets to provide safe care. Innovation and evidence must be a critical part of how care is delivered to this ever growing and very frail population. In an ideal world, the frail and vulnerable residents would have RNs providing all aspects of their care. However, in a fiscally constrained world, staff representing many levels of credentialing must be maximized to assure that care can be given. This study provides some initial evidence to suggest that medication technicians can be effectively used for routine medication administration. Understanding the limitations of the CMT/A (medication technicians) and creating medication systems that include the RN and the CMT/A as partners, could provide safe medication administration where residents get the right medication, at the right time, in the right dose, through the right route, and prepared in the right method to assure the most therapeutic result (Scott-Cawiezell, 2007a)” 4 (p. 6). Based upon their experience with the project and the results of the pilot study the Steering Committee recommends that: • Legislation be pursued to extend the role of the medication technician statewide; 18 • All features of the pilot study remain including protocols, education, setting, and testing; • The time frame for the training be paced so students can better comprehend the material; • The role of the RN in delegation and medication management be specifically addressed; • That the Board collaborate with the Department of Health Services and other licensing boards in crafting legislation. REFERENCES: 1. Scott-Cawiezell, J., Pepper, G., Madsen, R., Petroski, G., Vogelsmeir, A., and Zellmer, D. (2007). Nursing home error and level of staff credentials. Clinical Nursing Research. Vol. 16, No. 1, 72-78. 2. Barker, K., Flynn, E., & Pepper, G. 2002. Observation method of detecting medication errors. Am.J.Health Syst. Pharm. Vol. 59, Dec. 1, 2002; 3. Scott-Cawiezell, J., Pepper, G., Madsen, R., Petroski, G. Vogelsmeier, A., & Zellmer D (2007b). Final Report: Technology to Improve Medication Safety in Nursing Homes, submitted to the Agency for Healthcare Research and Quality. 4. D & S Diversified Technologies (2008). Arizona Pilot Study Medication Technician Final Report, submitted to the Arizona State Board of Nursing on 6/13/08. 5. Personal communication from Sheila Sorrentino, Mosby Author, regarding current work on a medication technician textbook due for release in 2008 on or about August 11, 2008. 6. Sorrentino, S. and Remmert, L. (2009) Mosby’s Textbook for Medication Assistants. Mosby, Inc. 7. Walker, M. (2008). Effects of the Medication Nursing Assistant Role on Nurse Job Satisfaction and Stress in Long-Term Care. Nursing Administration Quarterly. Vol. 32, No. 4, pp 296-300. 19 Appendix A 20 APPENDIX A Persons Contributing to the PMST Project* Board Member Chairs Sharon Molleo, LPN Steve Robertson, LPN M. Hunter Perry, Public Member Board Staff Joey Ridenour RN, MN, Executive Director Pamela Randolph RN, MS, Associate Director of Education and Evidence-based Regulation Lila Van Cuyk, RN, BSN, Education Consultant Rose Wilcox, RN, M.Ed., Education Consultant Karen Gilliland, Legal Secretary Pilot Facility Representatives Armida Dixon/Karen Truett, Heritage Health Care Debbie Madrid/Paula Mitchell, Copper Mountain Inn Sarah Ellis/Cathie Hauf, Good Shepherd Phyllis Jordan/Pat Collea/Regina Tutor, Silver Ridge Village Marie Montion/Jackie Arnett, Mountain View Barbara King/Annie Quarles, Shadow Mountain Committee Members 2004 Betty Earp RN, BSN, CNA Instructor Catherine Corbin, M.H.S., Arizona Department of Health Services Christine Walker, RN, NHA, Administrator, Kachina Point Dean Wright, R. Ph., Compliance Officer, AZ Board of Pharmacy Jane Black, RN, MS, Southern Arizona Nursing Coalition John Durbin, Alzheimer’s Association Joyceen Boyle, RN, Ph.D., Associate Dean, University of Arizona Kathleen Collins Pagels, Executive Director, Arizona Health Care Association Lindsey Norris, Executive Director, AZAHA Marla Weston, RN, MS, Executive Director, Arizona Nurses Association Mary Fermazin, MD, MPA, VP, Health Services Advisory Group Rose Pfefferrbaum, Ph.D, MPH, Director of Gerontology, Phoenix College Sarah Ellis, RN, DON, Good Shepherd Sue Macdonald RN, MS Director Cochise College Nursing Program Committee Members 2005 Betty Earp RN, BSN, CNA Instructor Catherine Corbin, M.H.S., Arizona Department of Health Services Christine Walker, RN, NHA, Administrator, Kachina Point Dean Wright, R. Ph., Compliance Officer, AZ Board of Pharmacy Debra Piluri, AZ Dept of Health Services Helen Houser, RN, Director of Gerontology, Phoenix College 21 Jane Black, RN, MS, Southern Arizona Nursing Coalition John Durbin, Alzheimer’s Association Joyceen Boyle, RN, Ph.D., Associate Dean, University of Arizona Kathleen Collins Pagels, Executive Director, Arizona Health Care Association Lindsey Norris, Executive Director, AZAHA Marla Weston, RN, MS, Executive Director, Arizona Nurses Association Mary Fermazin, MD, MPA, VP, Health Services Advisory Group Patt Rehn, RN, MS, Arizona Nurses Association Sarah Ellis, RN, DON, Good Shepherd Sue Macdonald RN, MS Director Cochise College Nursing Program Committee Members 2006 Anna Marie McNeese, RN, Graduate student ASU Betty Earp RN, BSN, CNA Instructor Cheryl Roat RN, MS, Associate Dean, Grand Canyon University Christine Walker, RN, NHA, Administrator, Kachina Point Dean Wright, R. Ph., Compliance Officer, AZ Board of Pharmacy Debra Piluri, AZ Dept of Health Services Helen Houser, RN, Director of Gerontology, Phoenix College Jane Black, RN, MS, Southern Arizona Nursing Coalition Jo Podjaski, RN, MSN, Clinical Educator, Sun Health John Durbin, Alzheimer’s Association Julie Gordon, Executive Director, AZAHA Kathleen Collins Pagels, Executive Director, Arizona Health Care Association Patt Rehn, RN, MS, Arizona Nurses Association Committee Members 2007 Betty Earp RN, BSN, CNA Instructor Cheryl Roat RN, MS, Associate Dean, Grand Canyon University Christine Walker, RN, NHA, Administrator, Kachina Point Dean Wright, R. Ph., Compliance Officer, AZ Board of Pharmacy Debra Piluri, AZ Dept of Health Services Genny Rose, Executive Director, AZAHA Jane Black, RN, MS, Southern Arizona Nursing Coalition Jo Podjaski, RN, MSN, Clinical Educator, Sun Health John Durbin, Alzheimer’s Association Kathleen Collins Pagels, Executive Director, Arizona Health Care Association Mary Griffith/Laurie House, Arizona Nurses Association Committee Members 2008 Betty Earp RN, BSN, CNA Instructor Cheryl Roat RN, MS, Associate Dean, Grand Canyon University Christine Walker, RN, NHA, Administrator, Kachina Point Dean Wright, R. Ph., Compliance Officer, AZ Board of Pharmacy Debra Piluri, AZ Dept of Health Services 22 Genny Rose, Executive Director, AZAHA Jane Black, RN, MS, Southern Arizona Nursing Coalition John Durbin, Alzheimer’s Association Kathleen Collins Pagels, Executive Director, Arizona Health Care Association Mary Griffith/Laurie House/Rory Hays, Arizona Nurses Association The following persons provided expert advice to the committee and the Board: Paul Dorrance/Chad Solis—D & S Diversified Technologies Jill Scott-Cawiezell, RN, Ph.D Ginny Pepper, RN, Ph.D Sue Roe, RN, Ph.D * While we have attempted to be inclusive in this list, we apologize for any inadvertent omissions 23 Appendix B 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 Appendix C 39 House Bill 2256 2004 AN ACT PROVIDING FOR A PILOT PROGRAM TO ALLOW CERTIFIED NURSING ASSISTANTS TO ADMINISTER MEDICATION. Be it enacted by the Legislature of the State of Arizona: Section 1. Pilot study medication technicians; pilot program A. The state board of nursing may establish a pilot program to determine the impact to patient health and safety of allowing nursing assistants certified pursuant to title 32, chapter 15 and acting as pilot study medication technicians to administer medications under educational requirements and conditions prescribed by the board. B. The board may conduct the pilot program in not more than six skilled nursing facilities. Acute and sub-acute patients shall be excluded from this study. C. Except as provided in this subsection, nursing facilities participating in the pilot program shall not replace existing registered nurse and licensed practical nurse positions with certified nursing assistants or pilot study medication technicians. The department of health services and board may authorize, as part of the pilot program, adjustments to nursing staff mix as necessary to conduct an evidence based study to determine the impact of varying staffing models upon patient health and safety. Facilities participating in the pilot program shall not violate state or federal laws relative to the adequacy of nursing coverage. D. The pilot program must include delegation and supervision protocols regarding which medications the pilot study medication technicians may and shall not administer and under what conditions. The protocols shall prohibit medication technicians from administering any medication or fluid by needle. The protocols must give registered nurses and licensed practical nurses the authority to refuse to delegate the administration of medication to pilot study medication technicians if a nurse believes that patient health and safety is at risk. E. The board may adopt policies prescribing the education and training requirements for certified nursing assistants participating in the pilot program as pilot study medication technicians. F. The board is authorized to charge the participating facilities and pilot study medication technicians an assessment to implement the provisions of this section. G. The board must complete the pilot program on or before December 1, 2008. 40 H. For the purposes of this act, the state board of nursing is exempt from rulemaking with regard to adopting policies to assist in the implementation of this act. The board shall hold public hearings to review, discuss and adopt the proposed policies. I. The board shall submit a written report on or before December 1, 2008 to the governor, the president of the senate and the speaker of the house of representatives regarding the results of the pilot program and recommendations for any administrative or legislative action. The board shall provide a copy of the report to the secretary of state and the director of the Arizona state library, archives and public records. 41 Appendix D 42 Delegation of Medications to Pilot-study Medication Technicians Protocols (Approved by AZBN 7/20/05) Introduction: Delegation means transferring to a competent individual the authority to perform a selected nursing task in a designated situation in which the nurse making the delegation retains accountability for the delegation (ARS 32-1601 (7)). The delegating nurse must make decisions within the context of the five rights of delegation: • Right task—Ensure that the activity may legally be delegated. The activity should not require nursing judgment, should have predictable results and unchanging procedures. Nurses may not delegate assessment or evaluation. • Right circumstance—Assess client, the complexity of the activity, and the nurse’s ability to supervise and monitor the client, the activity, and the personnel. • Right person—Identify the competency level of the personnel and the needs of the client on an individual basis. • Right communication—Communicate any specific data to be collected; variations in procedure; timelines; expected results • Right supervision/evaluation-- Monitor performance, provide feedback, evaluate client response (NCSBN, 1997) Protocols The purpose of these protocols is to identify the circumstances for which the nurse is allowed, under the pilot study (HB 2256), to delegate the administration of medications. A licensed nurse may delegate the administration of medications to pilot-study medication technicians (PSMT) who have completed a prescribed curriculum and passed an Arizona State Board of Nursing approved competency test. May Be Delegated: Under the pilot study conditions, the licensed nurse, when present and available to the PSMT, may delegate to the PSMT: • Regularly scheduled medications, including controlled substances, to residents by the following routes: oral, topical, nasal, otic (ear), optic (eye), and rectal • PRN or “as needed” medications for bowel care or over-the-counter analgesics. The nurse shall assess the need for the medication, evaluate the effect of the medication, and document findings in the resident record. • If a resident identifies a need for sublingual nitroglycerine and there is sublingual nitroglycerine available for the resident’s self-administration, the PMST may assist the resident in self-administration of the medication. 43 NOT Be Delegated: A nurse shall not delegate: • In situations where the delegation would pose an unacceptable risk of harm or jeopardize the health or welfare of the resident in the professional judgment of the nurse or where safe delegation cannot be accomplished. • The first dose: o Of a new medication, or o Of a previously prescribed medication when the dosage is changed. • Checking all new medications that arrive from the pharmacy to assure they reflect the original prescription. • PRN or “as needed” medications except as noted above. • The counting of controlled substances at the beginning and end of a shift. • Any medication delivered by a needle or by intradermal, subcutaneous, intramuscular, intravenous, intrathecal, and intraosseous routes. • Any medication that must be inserted into a nasogastric tube or gastric tube. • A change in oxygen settings or turning oxygen on/off. • Inhalant medications. • Regulation of intravenous fluids or programming insulin pumps. • Topical patches, topical medications requiring a sterile dressing or assessment of skin condition. • Sublingual medications (except as noted above—assisting in nitroglycerine) • Any medication that requires a mathematical conversion between units of measurement to determine the correct dose. A licensed nurse shall calculate all dosages that involve such conversions and write and initial the correct dosage on the administration record and the pharmacy label before a PSMT may administer the medication. The PSMT should verify that the calculation and dosage is correct before administration. 44 Appendix E 45 EDUCATIONAL GUIDELINES FOR FACILITIES Pilot-Study Medication Technician Education APPROVED BY THE BOARD September 21, 2005; REVISED March 27, 2007 An entity offering a course to train unlicensed personnel to administer medications shall adhere to the following guidelines. Admission Requirements: Admission into the training is limited to currently certified nursing assistants (CNA) who are at least 18 years old and who have: • • • • Worked at a pilot long-term care facility for a minimum of 3 months as a full time employee in a CNA position and have at least 6 months experience as a CNA; CPR certification; Earned a high school diploma or GED; The ability to succeed in the course, as determined by the Director of Nursing of the facility, utilizing the criteria below. The CNA: • Has a good attendance and employment record; • Demonstrates excellence and efficiency in performance of CNA skills; • Demonstrates ability to calculate simple dosages; • Demonstrates ability to read and comprehend a nursing assistant textbook; • Requires minimal supervision; • Works as a team member; • Verbalizes the desire to attend the program and carry out the duties of the medication technician; • Demonstrates respect for the process of medication administration; • Exhibits organizational skills in determining priorities in nursing assistant care; • Describes ability to manage time and resources to attend classes, study, and fulfill other obligations. Length of the Program: • • • The program shall consist of a minimum of 45 hours of didactic study, 15 hours of skills lab practice and 40 hours of supervised clinical following the Arizona State Board of Nursing approved curriculum plan The program shall provide15 hours of skills lab experience for the purpose of student practice and competency testing before a student is allowed to administer medication to a resident. Medication administration practice in the skills lab is included in the course syllabus and integrated into the didactic course content. Students must pass a skill lab evaluation utilizing Board-approved criteria before administration of medications to residents. There shall be a minimum of 40 hours of clinical practice utilizing the guidelines of progressive clinical practice and principles of supervision as detailed below 46 Educational Setting • • A long-term care facility chosen as a site for the pilot study may conduct training. All course instructors must complete a Board-approved “train-the-trainer” seminar sponsored by the Board consisting of 15 hours of instruction in teaching and curriculum including the specific curriculum of the PSMT course. Competency Testing • • • • CNAs who successfully complete the PSMT course shall be eligible to take a Board administered competency exam The Board shall develop a competency exam based on established principles of testing and curriculum content with both a written and manual skill portion and establish a passing standard. A board representative shall administer the competency examination within 30 days of course completion. During the period between course completion and examination, the graduate may administer medications only under the direct supervision of the instructor. Candidates who fail a portion of the competency exam on the first attempt, shall be offered one re-take of the failed portion within 30 days. Candidates who fail two times or both portions of the exam will be withdrawn from the PSMT program. Instructors • • • • • Instructors shall hold a registered nursing license in good standing. Instructors shall have worked at a long-term care facility for a minimum of one year as a registered nurse Instructors shall have experience teaching adults Instructors shall either complete a “train-the-trainer” course before teaching the PSMT course or otherwise demonstrate the knowledge, skill and ability to provide medication technician instruction: Instructors shall deliver all didactic instruction personally and shall not utilize guest lectures or assistants to teach any portion of the course to ensure consistency Clinical Practice • Progressive clinical practice of 40 hours to include: o One-to-one instructor observed medication passes until the instructor determines that the student is safe to progress, starting with a minimum of 5 residents progressing to 10 residents over a period of 3 days for 4 hours per day (12 hours). The instructor will observe, evaluate, and record student performance for each resident medication pass using a Board- 47 approved checklist. Students shall perform 30 medication administrations without coaching or missing critical elements to progress. o One-to-three instructor to student ratio for a minimum of 12 hours. The student may administer medications to10-15 residents. The instructor will utilize a Board-approved checklist to record student performance. The instructor shall observe, evaluate, and record performance of medications administered at a specific time to every 3 residents. Students shall perform 15 documented medication administrations without missing critical elements or coaching to progress. A licensed nurse (RN or LPN) shall check all medications for correct drug, time and dosage before administration and review all medication documentation. o Upon successful completion of the above, the student may progress to medication passes under the general supervision of the instructor for a minimum of 16 hours to the number of residents determined by the facility to consist of a normal assignment for a medication technician. The instructor-to-student ratio shall be 1:5. The instructor will utilize a Boardapproved checklist to record student performance. The instructor shall observe, evaluate, and record performance of medications administered at a specific time to every 5 residents. Students shall perform 15 documented medication administrations without coaching or missing critical elements to progress. A licensed nurse (RN or PN) shall check all medications before administration for correct drug, dosage, and time and review all medication administration documentation. o Following successful course completion and prior to taking and passing the Board administered competency exam, a PSMT course graduate may continue to administer medications to selected residents under the direct supervision of the instructor. Principles of Supervision 1. Student supervision is always conducted by the instructor throughout the course and until the student passes the Board administered competency examination. The instructor shall engage in no other duties during the period of supervision. 2. The student will progress in passing medications to progressively larger groups of residents as the student demonstrates consistent, safe, efficient medication administration according to Board-approved criteria. 3. The instructor or a licensed nurse will review all medication documentation. The review will be documented on the medical record. 4. All critical elements in the Board approved criteria must be performed by the student for all medication passes without coaching or cueing from the instructor for the student to progress from lab to clinical, to a larger number of residents, or to general supervision. 5. The instructor may require more practice than the minimum but in no instances shall less practice be required. 48 Delegating Nurses All nurses delegating administration of medication must complete a Board-approved training session on delegation. All nurses who delegate medication administration should review the medication administration record at least once per shift for all residents. 49 Appendix F 50 MEDICATION ADMINISTRATION FOR PILOT STUDY MEDICATION TECHNICIANS SYLLABUS/CURRICULUM APPROVED BY THE BOARD September 21, 2005 COURSE OVERVIEW: This course provides basic background information and routine procedures that are essential for the safe administration of select medications by experienced certified nursing assistants in a long term care facility. Content includes basic principles of medication administration, simple calculations, and categories of medications. Successful completion of the course and a “pass” on both the written and manual skills exam administered by the Arizona State Board of Nursing (AZBN) will meet the qualifications to become a pilot study medication technician (PSMT) and administer medications utilizing Arizona State Board of Nursing protocols at a selected long-term care facility under the supervision of a licensed nurse. Admission Requirements: Admission into the training is limited to currently certified nursing assistants (CNA) who are at least 18 years old and who have: • • • • Worked at a pilot long-term care facility for a minimum of 6 months as a full time employee in a CNA position; CPR certification; Earned a high school diploma or GED; The ability to succeed in the course, as determined by the Director of Nursing of the facility, utilizing the criteria below. The CNA: • Has a good attendance and employment record; • Demonstrates excellence and efficiency in performance of CNA skills; • Demonstrates ability to calculate simple dosages; • Demonstrates ability to read and comprehend a nursing assistant textbook; • Requires minimal supervision; • Works as a team member; • Verbalizes the desire to attend the program and carry out the duties of the medication technician; • Demonstrates respect for the process of medication administration; • Exhibits organizational skills in determining priorities in nursing assistant care; • Describes ability to manage time and resources to attend classes, study, and fulfill other obligations. 51 Length of the Program: • • • The program shall consist of a minimum of 45 hours of didactic study, 15 hours of skills lab practice and 40 hours of supervised clinical following the Arizona State Board of Nursing approved curriculum plan. The program shall provide15 hours of skills lab experience for the purpose of student practice and competency testing before a student is allowed to administer medication to a resident. Medication administration practice in the skills lab is included in the course syllabus and integrated into the didactic course content. Students must pass skills lab evaluation utilizing Board-approved criteria before administration of medications to residents. There shall be a minimum of 40 hours of clinical practice utilizing the guidelines of progressive clinical practice and principles of supervision as detailed below Clinical Practice: Progressive clinical practice of 40 hours to include: 1. One-to-one instructor observed medication passes until the instructor determines that the student is safe to progress, starting with a minimum of 5 residents progressing to 10 residents over a period of 3 days for 4 hours per day (12 hours). The instructor will observe, evaluate, and record student performance for each resident medication pass using a Board-approved checklist. Students shall perform 30 medication administrations without coaching or missing critical elements to progress. 2. One-to-three instructor-to-student ratio for a minimum of 12 hours. The student may administer medications to10-15 residents. The instructor will utilize a Boardapproved checklist to record student performance. The instructor shall observe, evaluate, and record performance of medications administered at a specific time to every 3 residents. Students shall perform 15 documented medication administrations without missing critical elements or coaching to progress. A licensed nurse (RN or LPN) shall check all medications for correct drug, time and dosage before administration and review all medication documentation. 3. Upon successful completion of the above, the student may progress to medication passes under the general supervision of the instructor for a minimum of 16 hours to the number of residents determined by the facility to consist of a normal assignment for a medication technician. The instructor-to-student ratio shall be 1:5. The instructor will utilize a Board-approved checklist to record student performance. The instructor shall observe, evaluate, and record performance of medications administered at a specific time to every 5 residents. Students shall perform 15 documented medication administrations without coaching or missing critical elements to progress. A licensed nurse (RN or PN) shall check all medications before administration for correct drug, dosage, and time and review all medication administration documentation. 4. Following successful course completion and prior to taking and passing the Board administered competency exam, a PSMT course graduate may continue 52 administer medications to selected residents under the direct supervision of the instructor consistent with the principles of supervision below. Principles of Supervision 1. Student supervision is always conducted by the instructor throughout the course and until the student passes the Board administered competency examination. The instructor shall engage in no other duties during the period of supervision. 2. The student will progress in passing medications to progressively larger groups of residents as the student demonstrates consistent, safe, efficient medication administration according to Board-approved criteria. 3. A licensed nurse (RN or PN) shall review all medication documentation. 4. All medications will be checked for right time, dose, and drug before administration; 5. All critical elements in the Board approved criteria must be performed by the student for all medication passes without coaching or cueing from the instructor for the student to progress from lab to clinical, to a larger number of residents, or to general supervision. 6. The instructor may require more practice than the minimum but in no instances shall less practice be required. Competency Testing • • • • CNAs who successfully complete the PSMT course shall be eligible to take a Board administered competency exam The Board shall develop a competency exam based on established principles of testing and curriculum content with both a written and manual skill portion and establish a passing standard. A board representative shall administer the competency examination within 30 days of course completion. During the period between course completion and examination, the graduate may administer medications only under the direct supervision of the instructor. Candidates who a fail a portion of the competency exam on the first attempt, shall be offered one re-take of the failed portion within 30 days. Candidates who fail two times or both portions of the exam will be withdrawn from the PSMT program. COURSE GOALS: Upon successful completion of the course, the student will be able to: 1. Explain the role of the pilot study medication technician in Arizona including allowable acts, conditions, and restrictions. 2. Discuss principles, terminology, laws, and drug references as they apply to administration of medications. 3. Explain principles of medication action. 53 4. Explain principles of medication administration and nursing care considerations for geriatric clients receiving medication. 5. Demonstrate application of mathematical concepts when preparing medications for administration. 6. Describe measures to promote safe medication administration in health care facilities. 7. Discuss medication properties, uses, adverse effects, administration, and nursing assistant care of residents receiving the following types of medications: a. Vitamins, minerals, and herbs b. Antimicrobials c. Eye and ear medications d. Skin medications e. Cardiovascular medications f. Respiratory medications g. Gastrointestinal medications h. Urinary system medications and medications to attain fluid balance i. Endocrine/reproductive medications j. Musculoskeletal medications k. Nervous system/sensory system medications l. Psychotropic medications CLINICAL COMPETENCIES A. Utilizing the 5 rights of medication administration, administer the following medications to stable residents when delegated and supervised by a licensed nurse: 1. Regularly scheduled oral, topical, nasal, and rectal medications. 2. PRN or “as needed” medications for bowel care or over-the-counter analgesics 3. Regularly scheduled ear and eye medications B. Demonstrate application of the principles of asepsis when administering medications. C. Follow principles of delegation when accepting delegation of medication administration. D. Accurately document medication administration. E. Perform nursing assistant care associated with medications administered to residents. F. Report any changes in resident condition to the delegating nurse. G. Adhere to Arizona State Board of Nursing Protocols during medication administration. H. Promote resident rights during medication administration. RESOURCES: Gauwitz, D. (2005). Administering Medications: Pharmacology for Health Careers. Boston: McGraw-Hill. Nursing Drug Manual Delegation Folder 54 Nursing Assistant Text ASBN Documents: Nurse Practice Act, Protocols, Research Scope of Work, HB2256 COURSE POLICIES: ATTENDANCE: ¾ The PCMT is a fast track course. Students must attend all classes to understand the material presented and function at a quality level in the health care setting. ¾ Students are required to complete the minimum hours of the course (45 didactic, 15 lab, 40 clinical practice) PASSING STANDARDS: Didactic/laboratory: ¾ There is not a single course grade for the training. Each of the following components must be completed satisfactorily for the student to pass the didactic/lab portion of the course: ƒ Four unit tests: the student must earn a minimum 75% on each unit test. If a student fails to achieve 75% on a test, an alternate form of the exam may be given for one test only. ƒ Dosage calculation test: the student must earn 100% on the dosage calculation test. A calculator may be used. Two retakes using alternate forms of the dosage calculation test are permitted. ƒ Comprehensive Course Test: the student must earn a minimum of 80% on the comprehensive course test. If a student fails to achieve 80% and has passed all unit tests on the first attempt, the student may re-take an alternate form of the comprehensive course test. ƒ Final skills laboratory: the final skills laboratory exam is Pass/Fail. The student must demonstrate all critical elements of selected medication administration to receive a grade of “pass.” If each competency is not met, the student will receive a grade of “fail.” ¾ The student must successfully complete the didactic and skills laboratory portion of the course as described above in order to proceed to the clinical practice portion of the course. Clinical practice: ¾ The student must complete the clinical practice within 45 days of completing the didactic and skills laboratory ¾ The student will receive a “pass” or “fail” grade for the clinical practicum; each competency must be met for the student to pass. ¾ The instructor will place an evaluation form in the students file indicating that the student has met all competencies for each of the 3 levels of clinical practice. The competencies of the previous level must be met to proceed to the next level. 55 COURSE COMPLETION: ¾ The student successfully meets the passing standards of the didactic/laboratory and ¾ The student successfully completes the clinical practicum. ¾ Upon successful course completion, the instructor will award a certificate to each successful trainee, which includes the trainee’s name, CNA certificate number, date of successful course completion, sponsoring institution, and instructor’s signature. ¾ The training facility will send copies of each student’s certificate of completion to the Arizona State Board of Nursing. RECORD MAINTENANCE: ¾ Course materials and student records will be retained by the training institution for 3 years. ¾ Course materials include the following: o Course syllabus o Course schedule o All tests and comprehensive exams o Student end-of-course evaluations ¾ Records for each student include the following: o Student name, date of birth, and CNA certificate number; o Attendance records including total hours for class, lab, and practicum; o All scores on tests and quizzes; o Skills check lists from clinical practice; o Instructor completed competency evaluation forms for each level of clinical practice; o Copy certificate of course completion. GRIEVANCE: A student may report a grievance related to the training through the established grievance process of the training institution. CONDUCT POLICY: The student is expected to conduct him/herself in an ethical and professional manner. A student who commits academic dishonesty and/or acts in an unprofessional manner will be removed from the PSMT training program. 56 Unit Objectives/Topical Outline/Assignments: Goal 1. Explain the role of the pilot study medication technician in Arizona including allowable acts, conditions, and restrictions. Objectives Content A. Discuss the legislation that led to the role of the pilot study medication technician. B. Explain the delegation process and the information a PSMT would need to accept delegation. C. Describe the Protocols under which a medication technician can administer drugs in Arizona D. Describe Board of Nursing role in the project and research components. A. Legislation HB 2256 B. Process of delegation/handouts Learning Activities Read: AZBN Protocols Nurse Practice Act—Rules/ Article 8 Legislation HB 2256; syllabus A-D Discussion Time for Unit Didactic: 1 hours C. Protocols D. Research components/testing Goal 2. Discuss principles, terminology, laws, and drug references as they apply to administration of medications Objective Content Learning Activity A. Define key terms A. Key terms: Read: pp 1-7, 8-13 Workbook: All B. List drug sources and uses C. Differentiate between different names for the same drug B. Sources and uses of drugs C. Drugs known by different names: chemical, generic and proprietary (trade) name D. Information D. Demonstrate use Time for unit Didactic: 1.5 hours B-D. Practice looking up a drug in nursing drug books, and on the internet and 57 of drug references E. Discuss drug legislation and how laws protect the public F. Apply legal, ethical, and caring behaviors when administering medications contained in drug references and types of drug references E. Major drug laws: 1. Food and Drug Act 2. Controlled Substance Act 3. Agencies that enforce drug laws F. Legal-ethical Resident rights, experimental drugs, placebos, caring principles—empathy, listening, hope, placebo effect discuss the information available E. Demonstrate how the facility complies with the controlled substance act— locked narcotics, wastage etc. Goal 3. Explain principles of medication action Objective Objective A. Define key terms Content Content A. Key terms p. 18 B. Describe the processes of drug absorption, distribution, metabolism, and excretion and resident education/care that will support the desired effects of drugs C. List and describe at least 10 factors affecting drug action. B. Processes of absorption, distribution, metabolism, and excretion and nursing assistant measures that support appropriate drug action C. Factors affecting drug action: age, size, diet, gender (male/female), genetics, diseases, psychological factors, routes of Learning Activity Time for unit Didactic: 2 Learning Activity hour Read pp. 18-29 Workbook: All items A. Play “key term” jeopardy where the definition is given and the participant supplies the correct term B-F Lecture; encourage discussion-ask students to: List personal factors that may affect drug actions; describe an adverse reaction from their own experience; Have they ever experienced tolerance, etc 58 administration, time of administration, drug taking history, environmental effects. D. Therapeutic/side D. Distinguish effects of drugs between therapeutic Local and systemic effects and side action effects of a drug E. Describe types of E. Adverse reactions; signs and symptoms; adverse reactions to nurse assistant drugs and nursing responsibilities for: assistant 1. Drug allergy responsibilities for 2. Tolerance each type of adverse 3. Cumulative Effect reaction. 4. Overdose and Toxicity 5. Drug interactions 6. Other drug related F. Drug dependence F. Differentiate and Abuse; nursing between drug assistant dependence and abuse in residents and responsibilities staff. F. Discuss risk for abuse among health care professionals Goal 4. Explain principles of medication administration and nursing care considerations for geriatric clients receiving medication. Objectives Content Learning Activities A. Recall the effects of aging on body systems A. Effects of aging on Read pp. 413-422 body systems Workbook: All items B. Discuss pharmacokinetics in the aged B. Pharmacokinetics in the aged C. Administer medications to elderly residents applying principles of safe medication administration, resident rights, and knowledge of aging C. Administration of medications to elderly residents: resident rights, safety principles, caring behaviors, difficult swallowing (thickening) Time for Unit Didactic: 1 hours A-C Lecture/discussion with examples Observation of medication administration 59 changes that may affect ability to take medications. Unit test #1 Goal 5. Demonstrate application of mathematical concepts when preparing medications for administration Objective Content Learning Activity A. Define key terms B. Recall common mathematical operations A. Key terms p. 36 B. Review of: 1. Fractions 2. Decimals C. Recognize different systems of measurement and when a licensed nurse needs to be involved. D. Write and define units of measurement for metric and household systems E. State common equivalents among measurement systems and use a conversion table to convert between systems F. Calculate the number of tablets or capsules to give when the available dose differs from the ordered dose. G. Calculate the amount of liquid medication to pour when the dose is ordered in units of mass. H. Verify a dosage C/D. Systems of measurement: 1. Metric 2. Household 3. Temperature scales 4. Apothecary (briefly) Read all of chapter except unit on apothecary (go over briefly in class) Workbook: see lab practice A. Key term jeopardy Time for unit 4 hours theory; 1 hour lab practice with examples (It is recommended that this content be divided into 2 days) B. Provide safe and unsafe examples of calculations E-H. 1. Equivalencies metric/household 2. Dosage calculation for oral medications 3. Dosage calculations with conversions— licensed nurse needed to do initial calculation Lab Practice: Use actual examples from your facility and workbook in class; students should complete workbook questions through 120 except the apothecary problems—a calculator may be used. 60 calculation using conversions from one system to another. Dosage Calculation Test Goal 6: Describe measures to promote safe medication administration in health care facilities. Objective Content Learning Activity Time for unit Didactic 5 Learning Activities Content Objective hours Reading: All sections A. Identify key terms A. Key terms p. 62 except vaginal, inhalation, B. Accepted B. Name common Lab parenteral and sublingual abbreviations abbreviations practice 3 Workbook: Substitute (supplemental associated with hours appropriate abbreviations JACHO medication from JACHO list (p 99 recommended) administration. #22-36) C. Forms of C. List medication Do workbook up to and medication: forms including #107 with 1. Liquids substitution of appropriate 2. Solutions abbreviations. 3. Suspensions 4. Solids/Semisolids A. Key term quiz B. Supplemental JACHO D. Routes of D. Describe routes abbreviations--quiz administration: for administering C-M. Lecture Oral routes: medications Discussion/Demonstration sublingual, buccal, Practice procedures: oral Medication set up— Topical Liquid/Tablet Rectal Documentation Eye drops Incident report Eardrops E. E. Recognize the Inhalation/Parenteral, routes of medication sublingual and PRN that may be medications—only administered by the licensed nurse gives PSMT F. International time F. Document time using international time (military time) G. Medication orders G. Describe the checked by nurse: licensed nurses responsibility to check 1. Order sheet 2. Prescription the components of a components medication order. a. Name of drug b. Dose 61 H. Describe the ordering, packaging, storage and disposal of drugs. I. Describe documentation used to communicate medication orders c. Route d. Time/frequency e. Prescriber signature 3. Types of drug orders; routine, standing, PRN, stat 4. Questioning an order H. Ordering, packaging, storage, and disposal of drugs I. Documentation: Medication Record Self-terminating Controlled substances J. Pouring medications J. Pour medications according to accepted procedure K. Explain the 5 rights K. The 5 rights of medication of medication administration: administration Drug, dose, patient, route time L. Charting L. Document medications medication MAR, principles of administration charting, reporting medication errors; M. Report and record M. Other types of observations that observations. require recording and reporting 62 Goal 7: Discuss medication properties, uses, adverse effects, administration of, education, and nursing assistant care of residents receiving the following types of medications: a. Vitamins, minerals, and herbs Objectives Content A. Key terms p.108 A. Identify Key Terms B. Identify fat soluble B. Vitamins and minerals and water soluble 1. RDAs/Food vitamins, sources macrominerals, and 2. Fat-soluble microminerals vitamins (A, D, E, and K) 3. Water soluble vitamins 5. Macro and Microminerals C. Functions of C. List one function vitamins and of each vitamin or minerals mineral D. Elevations and D. Recognize the dangers of elevated or lowered levels and effect on health lowered amounts of vitamins and minerals E. Herbs and unsafe E. Discuss common herbs herbal supplements, their uses, and the potential dangers. b. Antimicrobials Objectives A. Identify Key Terms B. Discuss types of infection, immunity and persons at risk for infection. C. Discuss considerations when administering Learning Activities Read: 107-117 Workbook: All items Key term quiz Emphasize key points and vitamins/minerals commonly given in the facility—do not require memorization of the charts in the chapter Relate information to their own health and intake of vitamins and diet Content Learning Activities A. Key terms p. 122 Read pp.122-134 Workbook: #1-34 Handout for Flagyl B. Microorganisms, the immune system, risks for infections, the geriatric resident C. Considerations when administering antibiotics Time for Unit Didactic: 1.5 hours A. Key term jeopardy B-E. Lecture/discussion with class participation— Include pertinent Time for Unit Didactic: 2 hour Lab Practice: 1 hour 63 MRSA, VRE, Cdifficile D. Differentiate major D. Categories, nursing assistant care categories of and administration antibiotics and the nursing assistant care considerations for: penicillins, and administration cephalosporins, considerations tetracyclines, associated with each macrolides, type: penicillins, aminoglycosides, cephalosporins, sulfonimides, and tetracyclines, Flagyl (see handout) macrolides, aminoglycosides, sulfonimides, and Flagyl E. Nursing assistant E. Discuss antiviral care and and antifungal drugs administration and the nursing considerations assistant care associated with associated with each antiviral and type. antifungal drugs (Flagyl). F. Review of standard F. Demonstrate and transmission administration of based precautions, medications to emphasis on residents with considerations when transmission-based administering precautions medications. antibiotics. information from supplemental articles from the Center for Disease Control (CDC) F. Demonstration/Return demonstration of administration of medications to residents with transmission based precautions—Use materials from CDC in instructor manual instead of book for this portion Unit Test #2 c. Eye and Ear medications Objectives Content A. Identify key terms A. Key terms p 147 B. Describe the B. Structure and structure, function, of function of the eye; the eye and administration of eye medication drops/ointments; administration effects of aging considerations when administering eye medications C. Describe ear C. Structure and Learning Activities Read: pp147-157 Workbook: 1-32 A. Key term matching quiz B-D Lecture/discussion E. Demonstration/return demonstration of ear drops and eye medications Time for Unit Didactic: 2 hour Lab Practice: 1 hour 64 structure, function, and the effect of aging on the auditory system. D. Identify common types of ear drops and eye medications E. Demonstrate administration of eye and ear medications (drops/ointments) function of the ear; effects of aging D. Ear drops/Eye medications E. Procedure for administration of eye and ear medications d. Skin medications Objectives Content A. Identify key terms B. Recall structure and function of integumentary system C. Discuss symptoms of skin disorders D. Discuss major categories of topical medications E. Identify those skin medications that should be administered by a licensed nurse. A. Key terms p 163 B. Structure and function of integumentary system C. General symptoms and specific features of common skin disorders D. Categories of topical medications: Keratolytics, protectives and astringents, antipruitics, antiinflammatory, antiseptics, topical anesthetics, miticides, transdermal E. Transdermal patches; medications requiring a sterile dressing change; medications requiring assessment of skin condition (Require licensed Learning Activities Read: pp 163-175 Workbook: #1-32 A. Key term jeopardy B-F Lecture/discussion/possible grand rounds if examples of disorders can be found within facility G. Demonstration/return demonstration Time for Unit Theory: 2 hours Lab practice: 1 hour 65 F. Identify general principles for medicating the skin and associated nursing assistant care. G. Demonstrate application of topical medications within PSMTprotocols nurse) F. Patient considerations; wound preparation; applying the medication; dressings; follow-up G. Principles of topical medication administration e. Cardiovascular medications Objectives Content Learning Activities Read: pp183-202 excluding section on blood/lymph p.193 B. Structure and Workbook: #1-35 function: heart, blood A. Key term quiz vessels, electrical B-D. conduction; blood Discuss/Lecture/case pressure, pulse (use study new Federal Guidelines for norms). E. Demonstration/return demonstration using blood, lymph, effects practice procedure 9.1 of aging substituting an C. Cardiovascular C. Discuss antiarrhythmic symptoms and symptoms and (propanolol) for disorders: CHF, characteristics of nitroglycerine Dysrhythmias, CAD, cardiovascular Blood vessel diseases, Propanolol 10 mg p.o. disorders qid. Shock, and anemia Add take radial pulse and blood pressure and D. Characteristics of D. Identify report to nurse before characteristics of and and nursing assistant administering— activity associated nursing assistant activities associated with administration of: otherwise procedure the same a digoxin. Diuretics, with administration antihypertensives, of common calcium channel classifications of blockers, A.C.E. cardiovascular inhibitors, medications within A. Identify key terms B. Recall structure and function of cardiovascular system A. Key terms Time for Unit Didactic: 3 hours Practice: 1 hour 66 PSMT protocols to administer. E. Administer oral cardiovascular drugs applying principles of safe drug administration specific to the resident and drug being administered. antilipemics, cardiac glycosides, antiarrhythmics, anticoagulants (oral), and hemateminics E. Principles of safely administering cardiovascular medications (pulse for digoxin; pulse and blood pressure for antiarrhythmics) f. Respiratory medications Objectives Content A. Identify key terms B. Recall structure and function of the respiratory system A. Key terms p 209 B. Structure and function of the respiratory system Learning activities Reading: pp. 209-219 Workbook: 1-36 A. Matching quiz key terms B-C. Lecture/Discussion/case study Time for Unit Didactic: 2 hour Lab: 1 hour C. Symptoms: Cough, sputum, D. Demonstration/return hoarseness, wheezing, chest pain demonstration—nasal medications Diseases: pneumonia, emphysema, asthma, tuberculosis, upper respiratory infection (colds; strept throat) D. Principles of D. Apply principles administering oral of safe drug and nasal respiratory administration and nursing assistant care medications and associated nursing specific to the assistant care. disorder when administering oral and nasal respiratory medications. Unit Test # 3 C. Discuss symptoms of respiratory distress and common diseases of the respiratory tract 67 g. Gastrointestinal medications Objectives Content A. Identify key terms B. Recall structure and function of the digestive system C. Identify symptoms of digestive disorders and characteristics of common disorders of the digestive tract A. Key terms D. Identify common classifications and characteristics of oral and rectal medications that affect the GI system including drugs used for bowel preparation. D. Common classifications of oral and rectal GI drugs: antacids, drugs to treat peptic ulcer, antiemetics, anticholinergics/antispasmodics, Antidiarrheals, antiinflammatory agents, and laxatives (bowel prep.). E. Apply principles of drug administration and nursing assistant care including potential drug interactions E. Administering rectal medications; review of oral medications; nursing assistant care/considerations when administering GI drugs/bowel preparation and medicated enemas. B. Process of digestion; Structure and function of the digestive system C. Symptoms: Nausea, vomiting, diarrhea, flatulence, eructation, constipation, pain Common disorders: constipation, tooth and gum disorders, peptic ulcer disease, hepatitis, gallbladder disorders, colitis, diverticulosis, hemorrhoids Learning Activities Reading: 236-258 (excluding administering medications through N/G tubes Workbook: all except 54-55 A. Key term quiz Time for Unit Didactic: 2 hours Lab: 2 hours B-D. Lecture/discussion/case study E. Demonstration of administration of rectal suppository and enema /return demonstration 68 when administering oral and rectal drugs that affect the gastrointestinal system h. Urinary system medications and medications to attain fluid balance Objectives Content Learning Activities Time for Unit Didactic: 1 Reading: pp 266-279 A. Identify key terms A. Key terms p 267 hours B. Review structure excluding bladder B. Recall structure instillation and function of and function of Workbook: urinary system urinary system A. Key term jeopardy C. Identify signs and C. 1.Common disorders B-E symptoms of Lecture/discussion/case common disorders of of the urinary system: obstruction, studies the urinary system. infection, renal and imbalances of failure body fluids, electrolytes and acid- 2. Imbalances of fluids, electrolytes, base and acid-base D. Review antibiotic D. Recall principles properties of antibiotics and apply knowledge to treatment of urinary disorders E. Discuss properties of diuretics and oral electrolytes including administration of and associated nursing assistant care. E. Diuretic types: thiazide, potassium sparing, loop, oral potassium; nursing assistant care considerations when administering diuretics and oral potassium 69 i. Endocrine medications/reproductive system Objectives Content Learning Activities A. Define key terms B. Identify structure and function of the endocrine glands: pituitary, thyroid, pancreas, and adrenal gland, reproductive system C. Discuss signs, symptoms and nursing care associated with the following endocrine disorders: diabetes mellitus, disorders of the adrenal gland, thyroid disorders, reproductive system disorders D. Identify the purpose of and administer oral endocrine medications demonstrating application of nursing assistant principles: oral diabetic agents (importance of diet/accuchecks), corticosteriods, thyroid replacement drugs; hormone replacement A. Key terms B. Structure and function of the endocrine glands C. Signs, symptoms and nurse assistant care of: diabetes mellitus, adrenal disorders, thyroid disorders D. Properties and nursing assistant care associated with administration of: oral diabetic agents (diet/accuchecks), corticosteroids, thyroid replacement drugs; hormone replacement drugs Reading: pp 305-321 pp. 292-299 except administering insulin, p 319 Workbook: #1-16, 25, 27-34 endocrine #15-21 (reproductive) A. Key term matching B-C. Lecture/discussion/ case study examples Lab Practice oral endocrine medications: 1 hour D. Demonstrate administration/return demonstration (Use oral medication check-off with common endocrine medications in your facility and scenarios) j. Musculoskeletal medications Objectives Content Learning Activities A. Define key terms B. Recall structure and function of the musculoskeletal Read: pp. 325-336 Workbook: #1-34 A. Key term quiz B-C A. Key terms p326 B. Structure and function of the musculoskeletal Time for Unit Didactic: 3 hours Time for Unit Didactic: 2 hour Lab practice: 1 70 system C. Discuss signs and symptoms, drug treatment and associated nursing assistant principals for the following disorders: Physical injuries, osteoporosis, bursitis, gout, osteoarthritis, and rheumatoid arthritis D. Administer drugs for disorders of the musculoskeletal system applying principles of care of residents with musculoskeletal disorders system: bones, joints, and muscles C. Signs and symptoms, drug treatment and associated nursing assistant care of residents with: Physical injuries, osteoporosis, bursitis, gout, osteoarthritis, and rheumatoid arthritis Lecture/discussion/Case examples D. Demonstration/return demonstration using NSAIDS prn medication order D. Drug characteristics and administration principles for common drugs used for muscloskeletal disorders: NSAIDs, Tylenol, methotrexate, antihyperuricemics, muscle relaxants and calcium and other drugs to treat osteoporosis k. Nervous System/Sensory System Medications Objectives Content Learning Activities A. Define key terms B. Recall structure and function of the nervous and sensory systems C. Discuss characteristics of nervous system disorders, drug treatment, and associated nursing assistant care: Parkinson’s disease, Myasthenia Gravis, Multiple Sclerosis, hour A. Key terms B. Review structure and function of the nervous and sensory system C. Nervous system disorders, drug treatment and associated nursing assistant care in the following disorders: Parkinson’s disease Myasthenia Gravis, Multiple Sclerosis, Epilepsy, Read: pp. 340-354 Workbook: #1-31 A. Key term jeopardy B-F Lecture/Discussion/Case Study Time for Unit Lecture: 2 hour Lab practice: 1 hour Lab practice: Administering PRN OTC medication for pain 71 Epilepsy, and Cerebral Vascular Accident. CVA D. Compare properties of drug classifications that affect the nervous system: Stimulants, Depressants including analgesics, anticonvulsants, antiparkinson agents D. Drug classification properties of Stimulants, Depressants including analgesics, anticonvulsants, antiparkinson agents E. Apply principles of drug administration for drugs affecting the central nervous system when administering medications. F. Discuss principles of administration of medications to treat pain E. Principles of administering CNS drugs F. Pain control principles Review of observing and reporting resident pain, nursing assistant care to relieve pain, administering medications to relieve pain, reporting response to nurse Unit Test #4 l. Psychotropic medications Objectives Content A. Define key terms B. Identify the signs and symptoms of major mental disorders: A. Key terms B. Signs and symptoms of major mental disorders: depression, anxiety, Learning Activities Read: pp.358-369 Workbook: #1-32 Time for Unit Didactic: 2 hour A. Key term jeopardy B-C 72 Lecture/discussion/exemplars D. Role play scenarios that incorporate refusal of C. Psychotropic drug medication and legal/ethical principles classifications: Antidepressants: tricyclic, SSRI’s Anti-anxiety agents, sedatives, antipsychotics, and lithium D. Legal-ethical D. Apply legal, ethical, and nursing considerations; caring behaviors in assistant caring administering behaviors when psychotropic drugs administering psychotropic drugs. depression, psychosis, anxiety, bi-polar disorder C. Describe classifications of psychotropic drugs, their uses and associated nursing assistant activities. psychosis, bi-polar disorder Final Exam—1 hours (add extra questions on psychotropic medications) Skill Check-off Exam—1 hour Didactic Instruction: 39 hours Tests: 6 hours (four unit tests, a dosage calculation test, and a comprehensive final) Total 45 hours didactic Lab hours: 14 Check-offs: 1 hour Total Lab 15 hours Didactic + Lab=60 hours 73 Appendix G 74 PILOT STUDY MEDICATION TECHNICIAN SCOPE OF WORK Approved by the Board 7/20/05 1. GENERAL REQUIREMENTS 1.1 The contractor shall provide research services further described in the Scope of Work which allow the Arizona State Board of Nursing (ASBN) to conduct a pilot study under the provisions of House Bill 2256. 1. 2 The contractor shall attend meetings and provide interim reports pertaining to the domain of this Request for Proposal with various ASBN representatives. The meetings may be requested by the ASBN or the contractor. 2. SPECIFIC REQUIREMENTS 2.1 The contractor shall conduct a pilot study under the provisions of House Bill 2256 to determine the impact to patient health and safety of allowing nursing assistants certified by the Board to act as pilot study medications technicians and administer medications under educational requirements and conditions prescribed by the Board. The pilot study shall include the following within the limits of the budget: 2.1.1. Medication error rate 2.1.1.1. Medication error rates shall be measured by a research assistant trained in and utilizing naive observation method as described by Barker and associates (Barker, K., Flynn, E., and Pepper, G. 2002. Observation method of detecting medication errors. Am.J.Health Syst. Pharm. Vol. 59, Dec. 1, 2002). 2.1.1.2. The study shall include no more than six skilled care facilities selected by the ASBN. 2.1.1.3. Observers shall gather data utilizing “naive observation” method whereby data collectors are unfamiliar with the residents and their medications for all observations. A minimum of 500 doses shall be observed both before and after the utilization of pilot-study medication technicians at each facility. (Barker, K., Flynn, E., and Pepper, G. 2002. Observation method of detecting medication errors. Am.J.Health Syst. Pharm. Vol. 59, Dec. 1, 2002) 2.1.1.4. The collection of medication error rates shall occur before the use of Pilot Study Medication Technicians (PSMT) and 6-12 months after the use of PSMT. 2.1.1.5. The contractor shall train and establish inter-rater reliability for all research assistants utilized in the collection of data. 2.1.2. Collection and analysis of other data to include: 2.1.2.1. Staffing patterns pre and post use of PSMT 2.1.2.2. Description of the role satisfaction of both the PSMT and the nurse through focus groups conducted in each pilot facility . 2.1.2.3. Any instances of diversion of controlled substances by the PSMT 75 2.1.3. For each category in 2.1.1. and 2.1.2., the contractor shall provide the following deliverables: 2.1.3.1 Measurement tools utilized for data collection, as needed, and the reliability and validity of the tool; 2.1.3.2.Telephone, e-mail and fax access to analysts; 2.1.3.3. Weekly or bi-weekly updates; 2.1.3.4. Electronic access to research findings. 2.1.4. The contractor’s research service shall be capable of providing various types of analysis, and reports. 2.1.5. The contractor’s research service shall permit the ASBN to reproduce and disseminate desired information in hard and electronic copy format. 2.1.5.1. The ASBN agrees that the service will be for informational purposes only and that it will not publish, broadcast, or sell any material retrieved from the contractor’s research files. 2.1.5.2. The ASBN agrees that the service will be for informational purposes only and that it will not use any information retrieved from the service in a fashion that would violate copyrights or proprietary interests of the contractor. 2.2 The contractor shall provide the following advisory services for the ASBN. 2.2.1. Assist in the review of the research study 2.2.2. Assist in the development of any statewide policy changes that arise from the study 2.3. The contractor shall utilize qualified personnel to collect and analyze the data. 2.4. The contractor shall provide a written and electronic copy of a report of study findings and recommendations. 2.4.1. The contractor’s report shall include, but not be limited to, the following information 2.4.1.1. An abstract of the study 2.4.1.2. A review of existing literature on the use of unlicensed personnel to administer medications. 2.4.1.3. A demographic description of the population studied 2.4.1.4. A description of the research design and methodology 2.4.1.5. A report of the data with accompanying charts and graphs as needed 2.4.1.6. An analysis of the data using appropriate statistical tests 2.4.1.7. A discussion of the findings 2.4.1.8. Recommendations 2.4.1.9. References 2.4.2. All findings and reports shall be released by the ASBN when deemed appropriate. The contractor shall not release findings and reports directly to other state agencies or the general-public without prior written consent of the Executive Director of the ASBN. 2.4.3 The contractor shall deliver the final report to the ASBN no later than June 1, 2008. 3. INVOICING REQUIREMENTS 76 3.1. The contractor shall be paid in installments with one-third of the total bid dispersed within 30 days of the award of the contract, one-third during collection of pre-utilization of Pilot Study Medication Technicians (PMST) data but not sooner than 90 days after the first installment, and one third within 30 days of receipt of all deliverables in the contract. 3.2.The contractor shall be paid in installments in accordance with the firm fixed prices stated on the Pricing Schedule. 77 Appendix H 78 GUIDELINES FOR PILOT FACILITY SELECTION (Approved by the Board 7/20/05; amended 10/4/05) Introduction: Ideally all selected facilities will meet all the guidelines listed below. However, given the complexity of the health care environment, the Pilot Study Medication Technician Steering Committee and the Arizona State Board of Nursing has the discretion to select facilities that may not meet one or more guidelines if the facility demonstrates that it has the resources and ability to successfully execute all aspects of the project. 1. All applicants must be licensed as long-term care facilities by the Department of Health Services (DHS). 2. Facilities are graded by DHS as either A, B, or C. In order to facilitate broad participation, ideally facilities chosen shall represent at least two of the three grades. 3. No facility will be chosen to participate in the pilot study with a medication error rate above 5% in the past 2 years. 4. No facility will be chosen to participate in the pilot study that received any survey deficiencies in staffing patterns for the last 2 years. 5. Facilities chosen to participate shall be free-standing and not based in an acute care health facility (hospital). 6. Facilities chosen to participate shall agree to the following terms of participation: • Agree to pay a participant fee of $5,000 within 10 days of being notified of selection to help offset the cost of the research • Provide qualified personnel and financial support for training, and competency testing (approximately $100 per participant) of pilot study medication technicians; • Assist in obtaining informed consent of participants and in the collection and compilation of data; • Provide assistance to the researcher including space for work, access to resident charts, access to reports, and any other assistance requested; • Allow DHS and the ABON to survey the training program and facility with or without notice; • Provide all course materials to PSMT students including textbooks, if any, practice medication cart, practice medications, medication administration records, and any other materials needed; • Provide a classroom and laboratory for training and practice that includes seating and writing surfaces for all students, and any other AV equipment needed to enhance delivery of course content; 79 • • Provide financial support for instructors to attend a minimum 15-hour training session (approximately $100 per instructor); Cover travel, supplies and incidental costs that are incurred by the Board to provide education to nurses on delegation responsibilities (at State of Arizona travel reimbursement rate and for actual cost of supplies). 7. All chosen facilities shall have conducted a Board-approved C.N.A. training for a minimum of 2 years. The program information on file at the Board offices shall not contain any of the following: substantial concerns with the program in a site visit report, letters of concern, notices of deficiency, or letters to the program indicating low results on the written or manual skills exam. 8. If an employee or representative of a pilot facility is a member of the PSMT steering committee, the employee or representative shall resign from the steering committee upon notification that the facility they represent is a pilot facility. 9. A pilot facility seeking to replace a RN or LPN position with additional CNA or medication technician positions shall provide evidence detailing the benefit of such a change in determining how various staffing mixes impact patient health and safety and seek approval from both the Department of Health Services and the Board before initiating the change in staffing. 80 Appendix I 81 The Written/Oral Test____________________________ The written test proctor will hand out materials and give instructions for taking the written test. You will have a maximum of sixty (60) minutes to complete the 50 question written test. You will be told when fifteen (10) minutes are left. You may not ask questions about the content of the written test (such as "What does this question mean?") Fill in only one (1) oval on the answer sheet for each question. DO NOT mark in the testing booklet. Marks in the test booklet will not be accepted as answers. Your answers must appear on the separate scan form answer sheet. You must have a score of 80% or better to pass the written portion of the test. All test materials must be left in the testing room. Anyone who takes or tries to take materials or information from the testing room is subject to prosecution. The Written Test consists of 50 multiple-choice questions. Questions are selected from subject areas based on the Arizona medication technician test plan. The subject areas and number of items for each area are as follows: Role of PSMT in Arizona (6 items) Underlying principles/laws/geriatric considerations (6 items) Medication calculations (5 items) Eye and ear medications (3 items) Vitamins, minerals, herbs (3 items) Antimicrobials (3 items) Medication administration (7 items) Musculoskeletal medications (3 items) Sensory / nervous system medications (3 items) Skin medications (3 items) Controlled substances (3 items) Cardiovascular medications (3 items) Respiratory medications (3 items) GI medications (3 items) Urinary system medications (1 item) Endocrine medications (4 items) Psychotropic medications (3 items) The Skill Test_________________________________ The purpose of the skill test is to evaluate your medication technician abilities. You will find a complete list of skill tasks in this handbook. Two (2) tasks will be randomly selected from the following list for you to perform as your skill test. The steps that are listed for each task are the steps required for a Medication Technician to completely demonstrate the skill task. You must have a score of 80% on each task without missing any key steps (the Bolded steps) to pass the skill portion of the test. If you fail a single task you will have to take another skill test with two tasks on it. What To Expect • • • • • • Each of two scenarios associated with your two assigned tasks will be read to you immediately before you do each task. After hearing a scenario you will go to and use the MAR to determine what medications to obtain from the locked medication cart and you will administer the medications obtained to a live resident actor. Listen carefully to all instructions given by the RN test observer. You may request to have either one of the scenarios repeated anytime during your skill test. Be sure you understand all instructions before you begin because you may not ask questions once the skill test begins. You will be given thirty (25) minutes to complete the two (2) tasks. You must correctly perform both tasks in order to pass the skill test. You will be told when 15 minutes have elapsed. 82 • If you believe you made a mistake while performing a task, say so and then repeat the task or the step on the task you believe you performed incorrectly. You may repeat any step or steps you believe you have performed incorrectly any time during your allotted 25 minutes or until you tell the RN test observer you are finished with the skill test. Once the skill test has begun, the RN test observer may not answer questions. ______________Manual Skill Tasks Listing________________ 1. Oral Liquid / Ear Drops Administration_________________________ 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) 16) 17) 18) 19) 20) 21) 22) 23) 24) 25) 26) 27) 28) 29) 30) Candidate uses hand sanitizer to clean hands. Candidate obtains correct medications from the medication cart For each medication verbally identifies the correct drug label for correct resident's MAR Verbalizes right drugs as the candidate obtains the medications from the cart For each medication verbalizes right doses as candidate compares the labels to right resident's MAR Medications selected are for the correct time Medications selected are for the correct routes Opens container Sets medication cup on level surface Pours correct amount of medication Checks for correct amount of medication at eye level Locks medication cart Greets resident Verbalizes right resident while using appropriate method of identification. i.e. picture, wrist band, or facility appropriate method of identification Introduces self as a medication technician Provides privacy Explains procedure Assists resident to take oral medication Lowers head of the bed Head is turned toward right with left ear upward Holds external ear flap and pulls up and back Instill two drops of medication into the ear Dropper tip does not touch inside of ear canal Tells resident to not move their head for a few minutes Returns medication bottle to the medication cart Locks medication cart Documents administration on the medication administration record on the correct day Maintains interpersonal communications during administration Places call light within reach Candidate uses hand sanitizer to clean hands. 2. Topical Medication / Unit Dose Administration_____________________ 1) 2) 3) 4) 5) 6) 7) 8) Candidate uses hand sanitizer to clean hands. Greets resident Verbalizes right resident while using appropriate method of identification. i.e. picture, wrist band, or facility appropriate method of identification Introduces self as a medication technician Provides privacy Explains procedure Listen to apical heart rate for 60 seconds with teaching stethoscope Record heart rate on the MAR 83 9) 10) 11) 12) 13) 14) 15) 16) 17) 18) 19) 20) 21) 22) 23) 24) 25) 26) 27) 28) 29) Recorded heart rate is within 5 beats of the observer's Verbalizes whether or not to proceed with medication administration based upon heart rate obtained Candidate obtains correct medications from the medication cart For each medication verbally identifies the correct drug label for correct resident's MAR Verbalizes right drugs as the candidate obtains the medications from the cart For each medication verbalizes right doses as candidate compares the labels to right resident's MAR Medications selected are for the correct time Medications selected are for the correct routes If candidate proceeds with tablet administration, places correct number of tablets into medication cup without touching the medication Locks medication cart If candidate proceeds with tablet administration, gives resident glass of water If candidate proceeds with tablet administration, assists resident to take medication Inspects right forearm skin area where medication is to be applied Instructs resident to turn face away while spraying One spray on area on forearm Returns spray bottle to the medication cart Locks medication cart Documents administration on the medication administration record on the correct day Maintains interpersonal communications during administration Places call light within reach Candidate uses hand sanitizer to clean hands. 3. Topical / Oral Capsule Medication Administration___________________ 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) 16) 17) 18) 19) 20) 21) 22) 23) 24) 25) 26) 27) 28) Candidate uses hand sanitizer to clean hands. Candidate obtains correct medications from the medication cart For each medication verbally identifies the correct drug label for correct resident's MAR Verbalizes right drugs as the candidate obtains the medications from the cart For each medication verbalizes right doses as candidate compares the labels to right resident's MAR Medications selected are for the correct time Medications selected are for the correct routes Puts capsule in medication cup without touching the medication Locks medication cart Greets resident Verbalizes right resident while using appropriate method of identification. i.e. picture, wrist band, or facility appropriate method of identification Introduces self as a medication technician Provides privacy Explains procedure Gives resident a glass of water Assists resident to take medication Inspects right forearm skin area where medication is to be applied Puts on one glove Opens container Applies ointment with gloved hand to forearm Spreads ointment to cover entire area that is to be treated Remove and discards glove Returns ointment tube to the medication cart Locks medication cart Documents administration on the medication administration record on the correct day Maintains interpersonal communications during administration Places call light within reach Candidate uses hand sanitizer to clean hands. 84 4. Oral Tablet Administration__________________________________ 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) 16) 17) 18) 19) 20) 21) 22) 23) 24) 25) 26) 27) 28) 29) 30) 31) 32) 33) 34) Candidate uses hand sanitizer to clean hands. Greets resident Verbalizes right resident while using appropriate method of identification. i.e. picture, wrist band, or facility appropriate method of identification Introduces self as a medication technician Provides privacy Explains procedure Listen to apical heart rate for 60 seconds with teaching stethoscope Record heart rate on the MAR Recorded heart rate is within 5 beats of the observer's Verbalizes whether or not to proceed with medication administration based upon heart rate obtained Candidate obtains correct medications from the medication cart For each medication verbally identifies the correct drug label for correct resident's MAR Verbalizes right drugs as the candidate obtains the medications from the cart For each medication verbalizes right doses as candidate compares the labels to right resident's MAR Medications selected are for the correct time Medications selected are for the correct routes If candidate proceeds with tablet administration, opens container If candidate proceeds with tablet administration, pours one tablet into medication cup without touching the medication Locks medication cart If candidate proceeds with tablet administration, gives resident a glass of water If candidate proceeds with tablet administration, assists the resident to take the medication Gently tilts resident's head back with chin up Pulls down on lower eye lid of the right eye making a pocket Asks resident to look up toward forehead Drops one drop of medication into the pocket Dropper tip does not touch eye Instructs resident to blink eyes Uses tissue to remove any excess fluid from around eye Returns medication bottle to the medication cart Locks medication cart Documents administration on the medication administration record on the correct day Maintains interpersonal communications during administration Places call light within reach Candidate uses hand sanitizer to clean hands. 5. Oral Capsule Administration_________________________________ 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) Candidate uses hand sanitizer to clean hands. Candidate obtains correct medications from the medication cart For each medication verbally identifies the correct drug label for correct resident's MAR Verbalizes right drugs as the candidate obtains the medications from the cart For each medication verbalizes right doses as candidate compares the labels to right resident's MAR Medications selected are for the correct time Medications selected are for the correct routes Opens first container Pours two capsules in medication cup without touching the medication Opens second container Pours one capsule into a medication cup without touching the medication Returns medications to proper place in medication cart Locks medication cart 85 14) Greets resident 15) Verbalizes right resident while using appropriate method of identification. i.e. picture, wrist band, or facility appropriate method of identification 16) Introduces self as a medication technician 17) Provides privacy 18) Explains procedure 19) Gives resident a glass of water 20) Assists the resident to take the medication one capsule at a time 21) Stays with the resident until the medication has been swallowed 22) Documents administration on the medication administration record on the correct day 23) Maintains interpersonal communications during administration 24) Candidate uses hand sanitizer to clean hands. 6. Oral Liquid / Ointment Administration__________________________ 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) 16) 17) 18) 19) 20) 21) 22) 23) 24) 25) 26) 27) 28) 29) 30) Candidate uses hand sanitizer to clean hands. Candidate obtains correct medications from the medication cart For each medication verbally identifies the correct drug label for correct resident's MAR Verbalizes right drugs as the candidate obtains the medications from the cart For each medication verbalizes right doses as candidate compares the labels to right resident's MAR Medications selected are for the correct time Medications selected are for the correct routes Opens container Sets medication cup on level surface Pours correct amount of medication Checks for correct amount of medication at eye level Locks medication cart Greets resident Verbalizes right resident while using appropriate method of identification. i.e. picture, wrist band, or facility appropriate method of identification Introduces self as a medication technician Provides privacy Explains procedure Assists resident to take medication Inspects right forearm skin area where medication is to be applied Puts on one glove Opens container Applies ointment with gloved hand to forearm Spreads ointment to cover entire area that is to be treated Remove and discards glove Returns ointment tube to the medication cart Locks medication cart Documents administration on the medication administration record on the correct day Maintains interpersonal communications during administration Places call light within reach Candidate uses hand sanitizer to clean hands. 7. Ear Drops / Tablet Administration_____________________________ 1) 2) 3) 4) 5) Candidate uses hand sanitizer to clean hands. Candidate obtains correct medications from the medication cart For each medication verbally identifies the correct drug label for correct resident's MAR Verbalizes right drugs as the candidate obtains the medications from the cart For each medication verbalizes right doses as candidate compares the labels to right resident's MAR 86 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) 16) 17) 18) 19) 20) 21) 22) 23) 24) 25) 26) 27) 28) 29) Medications selected are for the correct time Medications selected are for the correct routes Opens container Pours one tablet into medication cup without touching the medication Locks medication cart Greets resident Verbalizes right resident while using appropriate method of identification. i.e. picture, wrist band, or facility appropriate method of identification Introduces self as a medication technician Provides privacy Explains procedure Gives resident a glass of water Assists the resident to take the medication Lowers head of the bed Head is turned toward right with left ear upward Holds external ear flap and pulls up and back Instill two drops of medication into the ear Dropper tip does not touch inside of ear canal Tells resident to not move their head for a few minutes Returns medication bottle to the medication cart Locks medication cart Documents administration on the medication administration record on the correct day Maintains interpersonal communications during administration Places call light within reach Candidate uses hand sanitizer to clean hands. 8. Nasal Spray / Tablet Administration___________________________ 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) 16) 17) 18) 19) 20) 21) 22) 23) 24) 25) 26) Candidate uses hand sanitizer to clean hands. Candidate obtains correct medication bottles from the medication cart For each medication verbally identifies the correct drug label for correct resident's MAR Verbalizes right drugs as the candidate obtains the medications from the cart For each medication verbalizes right doses as candidate compares the labels to right resident's MAR Medications selected are for the correct time Medications selected are for the correct routes Opens container Does not contaminate lid Pours correct number of tablets into medication cup without touching Locks medication cart Greets resident Verbalizes right resident while using appropriate method of identification. i.e. picture, wrist band, or facility appropriate method of identification Introduces self as a medication technician Provides privacy Explains procedure the medication Gives resident glass of water Assists resident to take medication Have resident blow nose Tilts head back Instructs resident to hold head back Administers one spray in one nostril Returns medication bottle to the medication cart Locks medication cart Documents administration on the medication administration record on the correct day 87 27) Maintains interpersonal communications during administration 28) Places call light within reach 29) Candidate uses hand sanitizer to clean hands. 9. Eye Drops / Tablet Administration_____________________________ 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) 16) 17) 18) 19) 20) 21) 22) 23) 24) 25) 26) 27) 28) 29) 30) Candidate uses hand sanitizer to clean hands. Candidate obtains correct medications from the medication cart For each medication verbally identifies the correct drug label for correct resident's MAR Verbalizes right drugs as the candidate obtains the medications from the cart For each medication verbalizes right doses as candidate compares the labels to right resident's MAR Medications selected are for the correct time Medications selected are for the correct routes Opens container Pours one tablet into medication cup without touching the medication Locks medication cart Greets resident Verbalizes right resident while using appropriate method of identification. i.e. picture, wrist band, or facility appropriate method of identification Introduces self as a medication technician Provides privacy Explains procedure Gives resident a glass of water Assists the resident to take the medication Gently tilts resident's head back with chin up Pulls down on lower eye lid of the right eye making a pocket Asks resident to look up toward forehead Drops one drop of medication into the pocket Dropper tip does not touch eye Instructs resident to blink eyes Uses tissue to remove any excess fluid from around eye Returns medication bottle to the medication cart Locks medication cart Documents administration on the medication administration record on the correct day Maintains interpersonal communications during administration Places call light within reach Candidate uses hand sanitizer to clean hands. 88 Appendix J 89 Janet Napolitano Joey Ridenour Governor Executive Director Arizona State Board of Nursing Instructors Training Course Medication Technician Pilot Study Packet Contents 1. Goals/Agenda/Evaluation For Today’s Session 2. Overview of Project a. PowerPoint Presentation b. House Bill 2256 c. Scope of Work 3. Protocols a. Delegation Protocols 4. Scope of Practice a. CNA Minimum Competencies 5. Students: Selection, Supervision and Other Topics a. PowerPoint Presentation b. Educational Guidelines for Facilities 6. Teaching/Learning a. PowerPoint Presentation b. Supplemental Materials for Teaching Learning 7. Testing 8. Delegation a. PowerPoint Presentation b. Supplemental Materials 9. Course Overview a. Syllabus b. Procedure Checklists c. Curriculum Supplemental Materials 90 d. Evaluation Form for Students 91 Appendix K 92 ARIZONA PILOT STUDY MEDICATION TECHNICIAN Submitted by D&S Diversified Technologies, LLP dba HEADMASTER, LLP Final Report Submitted -- 6-13-08 Executive Summary Providing safe nursing home care is both a clinical and fiscal challenge that has resulted in the addition of medication technicians to nursing home health care teams in many states. The state of Arizona also faces many of these clinical and fiscal challenges; therefore the State Board of Nursing was authorized by the Arizona Legislature (HB 2256) to conduct a pilot study to explore the impact to patient health and safety if trained and certified medication technicians were added to selected Arizona nursing home care teams. To complete the study, medication administrators across various credentialing levels (LPN, RN, and Medication Technician) were observed for four types of medication error rates (wrong drug, wrong dose, wrong route, wrong time) The Pilot Study Medication Technician (PSMT) project included baseline naïve observation of medication administration in six nursing homes, identification and training of medication technicians, naïve observation six months after the role of the medication technicians was integrated into the medication administration team in five nursing homes; and interviews with selected stakeholders to determine the impact of the addition of CMTs through the perceptions of the team members. The study sought to determine if the pattern of medication error was different with the addition of medication technicians to the medication administration team at the five nursing homes that completed the study. While the sample size precluded statistically significant inferences, the findings do indicate that the pattern of medication error remained stable with no clinically or statistically significant differences noted among the medication administrators’ mean error rates both pre-implementation (LPN, 10.12%, RN 11.54%) and post-implementation (Medication Technicians, 6.08%, LPN 7.25%, and RN 2.75%). Reference a full report of the data in Appendix Two. These findings are similar to a national study funded by the Agency for Healthcare Research and Quality and conducted by Scott-Cawiezell and colleagues (2007a; 2007b). The study also found that members of the medication team were positively impacted by the presence of the medication technician over time. Based upon the study’s findings and the results of larger scale studies in other states, the research team recommends to the Arizona State Board of Nursing that they consider the integration of the medication technician role into the nursing home healthcare provider team within the scope of practice and supervision dictated during this project. 93 Overview of the Pilot Study of Medication Technicians Nursing homes have many challenges in the midst of very fiscally constrained budgets to provide safe care. Innovation and evidence must be a critical part of how care is delivered to this ever growing and very frail population. In an ideal world, the frail and vulnerable residents would have RNs providing all aspects of their care. However, in a fiscally constrained world, staff representing many levels of credentialing must be maximized to assure that care can be given (Scott-Cawiezell et al., 2007a; 2007b). Therefore, to meet the needs of the frail and elderly in the state of Arizona the following pilot study was completed in order to systematically assess the impact of adding medication technicians in the state of Arizona. Board Actions To implement the provisions of HB 2256, the Board completed the following activities: • Formed a steering committee that included stakeholders from long-term care, education, Board of Pharmacy, and nursing associations; • Adopted protocols for the administration of medications by pilot study medication technicians; • Developed selection criteria for pilot facilities (Appendix Four) and selected six facilities: Good Shepherd (Peoria), Shadow Mountain (Scottsdale), Mountain View (Tucson), Silver Ridge Village (Bullhead City), Copper Mountain Inn (Globe), Heritage Health Care (Globe); • Developed educational criteria for students and instructors and curriculum; • Developed research guidelines and, through the efforts of Kathleen Pagels and the Arizona Health Care Association, raised $60,000 to help fund the research; • Issued an RFP through the Arizona Health Care Association; • Selected D and S Diversified Technologies to conduct the research with the collaboration of Dr. Jill Scott-Cawiezell • Assisted D and S Diversified Technologies to develop and implement a legally defensible and psychometrically sound written and manual skills competency exam • Conducted instructor training and delegation training at each facility; • Visited each facility during training; • Twenty one Medication Technicians trained and passed the competency exam to date Research Design and Methodology Nursing homes from across Arizona applied and six were selected to participate in the pilot study to determine if the pattern of medication error changed with the addition of medication technicians to the medication administration teams. A seventh nursing home was designated the alternate for the study. Research nurses observed medication delivery pre-implementation and post-implementation (six months after the introduction of medication technicians) using “naive observation” methods initially described by Barker and colleagues. The naïve observation methods assured that data collectors recorded precisely what was observed. This method has been used in several federally funded studies in medication safety (Barker Flynn, & Pepper, 2002; Scott-Cawiezell et al., 2007a; 2007b). Prior to observing any pre-implementation medication passes, the research team completed nurse observer training and established inter-observer reliability as the first step of the study. D&S DT hired consultant Barbara Sutherlin, RN, to observe and certify four Arizona RN observers using guidelines that were reviewed by the research consultant (see Appendix 1). The classroom portion 94 of the nurse observer training was conducted March 8, 2006. Subject matter for the training included the method of observation, procedures to follow, using the observation form, categorizing errors by type, resident confidentiality, and using the drug reconciliation method to determine possible scheduled drug diversions. Then two live medication pass observations were conducted during the morning shift and two during the evening shift the afternoon/evening of March 8th, all day March 9th, and the afternoon/evening of March 10th. Each nurse observer was trained (performed their base line observations) individually and their observations were correlated to the trainer who was the constant in all the base line observations. Observations were conducted on separate units; observed subjects were four licensed practical nurses (LPNs). (The facility used only LPNs to pass medications.) The trainer (Barbara Sutherlin, RN) and each nurse observer trainee individually recorded findings gathered during the base line observations on separate medication pass worksheets. The findings of the nurse observer and trainer were not divulged (shared with each other) during the medication pass. Agreements versus disagreements were documented after the observations concluded. The inter-observer reliability coefficient was calculated using the formula described by Alberto and Troutman (1982) which considers agreements divided by agreements plus disagreements. The resulting calculated range of 95% to 99% is recognized as high inter-rater reliability and acceptable for the purposes of this study. During the second round of data collection for the actual study (post-implementation phase) all observations were completed by the same trained nurse observer and thus inter-observer reliability considerations became a non variable. 95 Data Analysis Data was analyzed using tests of group differences including ANOVA, and appropriate post hocs analyses (See Appendix Two). Limitations related to the nested nature of the observations (preimplementation, n=3039 medications observed in six facilities; and post-implementation n=2,521 medications observed in five facilities) was considered. Results Summary of the Naïve Observation of Medication Error Rates During the pre-implementation naive observations at the six pilot nursing homes 31 LPN’s and 7 RN’s were observed while delivering 3039 medications. The LPNs and RNs were sampled and observed in proportion to the actual medications delivered in the study facilities by credentialed level. The initial observations resulted in a mean medication error rate of 10.4% (LPN, 10.12%; RN, 11.54%). There were no statistical or clinical differences noted among the medication error rates observed. A second observation was conducted post-implementation at the five remaining study facilities, observing 16 LPN’s, 2 RN’s and 7 medication technicians delivering 2521 medications, again sampling was completed in proportion to the actual distribution of credentialed level. The postimplementation observation resulted in a mean medication error rate of 6.6% (LPN, 7.25%; RN, 2.75%; Medication Technician, 6.06%). Again, there were no statistical or clinically significant differences noted among the medication administrators regardless of the credentialed level. Summary of Key Informant Opinions on the Impact of the Addition of the Medication Technician Role A total of 22 staff members and leaders from the five nursing homes were interviewed after the post pilot study intervention data collection period. The interviews were conducted in two phases as facilities completed the data collection process after the intervention. The sample included Directors of Nursing (DONs), Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Pilot Study Medication Technician (PSMTs). The majority of respondents worked a minimum of 35 hours per week. The range of experience was 1 to 23 years in their roles. Those interviewed work a variety of shifts. However, all interviews (with the exception of the DONs) had medication administration as a part of their current role. Of the informants that were routinely involved in passing medications, the current percentage of time that they passed medications ranged from 10% to 90%. All informants were asked to discuss the changes in their roles with the addition of the medication technician’s to the care team. Despite some early misgivings about the new medication technician role, all licensed personnel (RNs and LPNs) reported that when they were able to partner with a PSMT, they did have more time to work directly with the residents. They reported feeling better about their treatments and more complete assessments. “The concept is fabulous, I now have more time to assess my residents and work with other staff. In the past, I felt stuck behind the med cart.” 96 “…nurses are now more available.” “…it is hard when the techs aren’t here, they are good partners.” The PSMTs also reported that it was their perception that their LPN and RN partners were spending more time with the residents. However, they also indicated that the success of the role was also impacted by their licensed partner. “I had a very difficult time in my new role at first. My nurse was constantly looking over my shoulder and making me very nervous. I could not get the pass done. Now, I have a new partner and I love what I am doing. We work really well together. “ A noteworthy finding was that one facility has had a great deal of difficulty in securing adequate staffing to fully and consistently implement the PSMT role. Although those staff could see benefit from the addition of the role, they also reported frustration in the inconsistencies of having the PSMT as their partner. The sample of informants shared various additional roles along with their medication administration responsibilities. Some PSMTs reported tailored shifts to maximize the medication administrations that they could be involved in and often they were also involved in related procedures. All reported that they routinely assisted other staff and residents when they were not passing medications. The informants were consistent in what medications were being passed by the PSMTs and the licensed staff. Licensed staff reported that, at times, the sharing of medication responsibilities was a challenge. However, they were learning systems to keep track of such things as needed (prn) narcotics and inhalers. All but one informant reported the residents were very happy with the addition of the PSMT role. “They miss her when she is gone, the resident keeps asking me where [she] is today.” “Residents are glad for the change; they don’t have to wait for their meds.” The exception was a licensed person who felt that she had spoiled the residents and they were getting inconsistent time with the PSMT so they had not yet gotten used to the change. Informants reported minimal changes to the medication administration procedure. They also reported minimal changes to the error reporting. No informants reported any perceptions of more medication errors and many reported they believed there were actually fewer medication errors and they were sure that there was a significant improvement in on time delivery of medications. Finally, informants shared recommendations and lessons learned during the pilot medication technician project. The recommendations include: • The timeframe for the training was too condensed. The training needs to be more spread out to allow time to study the critical concepts. • We need more PSMTs and they need to be consistently assigned to the role to improve and build systems. • Licensed staff would like to review the training so there can be consistent reinforcements for the PSMTs. 97 The lessons learned include: • Speed comes with time, the key is being very careful. • I now understand why blood pressures are so important for the medication pass and I always double check them myself. Now I know why my nurse was always asking me what their blood pressure is. • PSMT add flexibility to staffing. Discussion & Conclusions While the sample size and limited scope of the pilot study preclude large scale generalization of the findings; it can be noted that medication errors rates did appear to remain stably distributed among the various levels of credentialing in the medication administration team. These findings would suggest that the introduction of the medication technician did not alter the rate of medication error. Additionally, the findings are in line with both the early and final reports from the AHRQ funded medication safety study (Scott-Cawiezell et al., 2007a; 2007b), again providing further support that the introduction of medication technicians did not negatively impact the provision of care to nursing home residents. In addition to the analysis of medication error rates, key informants consistently reported positive results with the addition of the medication technician to the healthcare team. While the Arizona pilot study confirms earlier studies which indicate that medication technicians can provide safe medication delivery, many factors remain to be addressed. Nursing home residents have many illnesses, they take many medications, and they are very vulnerable to subtle alterations in their medication regimens. Many of the medications delivered in a routine medication administration do require assessment for potential adverse effects and CMT/As lack the assessment skills and knowledge to make adjustments or watch for many potential ADEs. Therefore, it is imperative as the Arizona State Board of Nursing moves forward that the role of the RN remain critical and clear in the management of resident’s medication. Nursing homes have many challenges in the midst of very fiscally constrained budgets to provide safe care. Innovation and evidence must be a critical part of how care is delivered to this ever growing and very frail population. In an ideal world, the frail and vulnerable residents would have RNs providing all aspects of their care. However, in a fiscally constrained world, staff representing many levels of credentialing must be maximized to assure that care can be given. This study provides some initial evidence to suggest that CMT/As can be effectively used for routine medication administration. Understanding the limitations of the CMT/A and creating medication systems that include the RN and the CMT/A as partners, could provide a safe medication administration where residents get the right medication, at the right time, in the right dose, through the right route, and prepared in the right method to assure the most therapeutic result (Scott-Cawiezell, 2007a). Based upon the PSMT results and interviews the research team can report the following: 1) 2) 3) There appears to be no reduction in the quality of care for Arizona nursing home residents do to the inclusion of medication technicians on the health care team. Therefore, their addition to the health care team could be implemented state-wide. The time frame for any future medication technician training should be extended to allow the students to pace their learning. The role of any future medication technicians should be consistently implemented to allow for medication processes to be constant from day to day. 98 4) The role of the RN in medication management should be explicitly clarified to complement the role of the medication technician in any system implemented for the routine administration of medications. 99 References Alberto, Paul A. and Troutman, Anne C., Applied Behavior Analysis for Teachers, Charles E. Merrill Publishing Co., Columbus, OH, 1982, Chapter 4, page 114. Barker, K., Flynn, E., & Pepper, G. 2002. Observation method of detecting medication errors. Am.J.Health Syst. Pharm. Vol. 59, Dec. 1, 2002; Scott-Cawiezell, J., Pepper, G., Madsen, R., Petroski, G. Vogelsmeier, A., & Zellmer D. (2007a). Level of nursing credential and interruptions: What is the impact on nursing home medication accuracy? Clinical Nursing Research, 16(1), 58-71. Scott-Cawiezell, J., Pepper, G., Madsen, R., Petroski, G. Vogelsmeier, A., & Zellmer D (2007b). Final Report: Technology to Improve Medication Safety in Nursing Homes, submitted to the Agency for Healthcare Research and Quality. Wilhelms, , Erica, Using an Observation-Based System to Track and Reduce Medication Errors, Pharmacy Purchasing & Products, Volume 3, Number 1. 100 Research Team D&S Diversified Technologies, LLP dba HEADMASTER, LLP D&S DT Project Team Team Manager, Paul Dorrance BA Mathematics, General Partner D&S DT Consultant RN, Barbara Ann Sutherlin RN, ME, D&S DT Staff RN Statistical Analysis, Ben Schmitt BS Mathematics, General Partner D&S DT Project Operations, Tim Petrick, Director of D&S DT Company Operations D&S Diversified Technologies, LLP dba HEADMASTER, LLP 3310 McHugh Ln Helena, MT, 59602 406-442-8656 Consultant Researcher, Jill Scott-Cawiezell PhD, RN, FAAN Associate Professor University of Missouri-Columbia S326 Sinclair School of Nursing Columbia, MO 65211 573-882-0264/Fax: 573-884-4544 scottji@missouri.edu 101 Appendix One--Observer Training Guide Medication Errors to be Tracked • • • • Wrong medication – any medication given that was not ordered by the physician Wrong dose – any dose that varies from the written order. Within wrong dose are subcategories: over, under, too strong, and too weak. Wrong route – administering a medication by the wrong route, such as giving an oral tablet when a suppository is ordered (note: for the purposes of this research, g-tube, injectibles, inhalers and prn narcotic medications will not be considered since medication technicians are not allowed to give medications by these routes). Wrong time – administering a medication at a time other than that ordered by the physician o Administering an ac medication with or after a meal or prior to 30 minutes before a meal. o Administering a pc medication before or with a meal or longer than 30 minutes after the meal. o Administering a medication plus or minus 60 minutes or more from the time that is scheduled Observational Method When You Arrive • Upon your arrival introduce yourself to the NHA, DON or the designee you have been directed to check in with. • Review the script for goals of the observation. • Share the procedure you will use to choose a unit for doing the observations after you have obtained the critical demographics about the units (Medicare unit, specialty unit, size of units, who as the largest medication load). • Review the scope of practice for each level of credentialing of medication administrators. Set up your observations so you will be seeing a proportional sample of RN, LPNs, and Medication Technicians (relative to the facility) as you observe your opportunities for error among the routine medications (excluding g-tube, injectibles, inhalers, and prn narcotics). Therefore, make sure you clarify with the nursing home leadership what percentage of routine medications each level of credentialed medication administrator gives on a typical day. For example, during the initial visit if the nursing home has 80% of the routine medications administered by LPN’s and 20% by RN’s then you should attempt to observe 80% of the medications passed by LPNs and 20% of your observations with RNs. If the nursing home has the RN only delivering insulin and prns then you will only observe LPN administrators. Subsequently, during your the post observations if 30% of the medications are administered by medication technicians, 60% of the medications are administered by LPN’s and 10% of the medications are administered by RN’s then you will attempt to approximate this same distribution in your observations. Getting Started • Introduce yourself to the medication administrator. Share with the medication administrator that you will try to remain unobtrusive and that your primary goal is to learn from them about the challenges of the medication administration process (take the focus off of individual errors and relieve their anxiety about being watched). • Ask the medication administrator to try to adhere to their routine as much as possible with the exception of reading out loud necessary information from the medication label as they are placing each medication in the medication cup. • At no point during the observation will the observer review the MAR except to see the picture of the resident that may be in the top corner. Questions should be held to a minimum and only for clarifications purposes. • Share with the medication administrator that you will be documenting exactly what you see them do, and you will remain unaware of what they should be doing until you have completed the medication observation and reviewed the medication administration record and the medical record. At that time, if there are consequential errors found they will be shared with the medication administrator and involved staff for immediate correction and then summarized to the DON at the end of the visit. (The 102 • • goal is to keep the error disconnected from any individual to maintain confidentiality of the individuals observed.) Inform the medication administrator, that while you are naïve to the medications that the resident should receive, there are medication administration principles and if you have concern about the resident’s imminent well-being you will ask the medication administrator to come out in the hallway for discussion. This would be a rare exception such as the medication administrator is crushing a large dose of an extended release medication and you know this would be hazardous to the resident. For the first observation in the facility or on a new unit, clarify any procedural issues: o How to they identify the residents? o Do they have pictures and where are the kept? o Do they have medications anywhere besides in the resident’s medication drawer. o How are stock medications managed? Observing a medication administration • Prepare to record all aspects of the medication episode (one resident) on the data collection form, using a separate line for each medication administered. • Note the resident’s name and room number, clarifying spelling as necessary to ensure that you can make a match to a medical record later. Note the photo of the resident if available; otherwise confirm that resident identification procedures have been completed (i.e. electronic I button, etc.) (Document on Medication Administration Observation Worksheet Column 1 & 2) • Record all medications that are prepared to be given to the resident, including medication name, dose, route, and any preparation technique (crushed, in thickened liquids, etc.). (Document on Medication Administration Observation Worksheet Column 3, 4, 5 & 6) • Walk into the room with the medication administrator and observe the identification process. • Observe the administration of the medications noting any monitoring or concerns related to technique, resident refusal, or resident concerns such as loose stools etc. (Document on Medication Administration Observation Worksheet Columns 7, 9, 10, 11 & comments) • Document the time of the administration. (Document on Medication Administration Observation Worksheet Column 8) Medication Administration Record Review and Medical Record Review • Review the medication administration record and compare each medication for a match to medication, dose, route, preparation technique, monitoring requirements, and time the medication was to be given. • Review the medical record for all medication orders written in the last ninety days that related to the medications you have observed as given or which should have been given to the resident and note any additional discrepancies. • Note any discrepancies on your Medication Reconciliation worksheet (either on a lap top or the provided second worksheet). Follow up Medication Administration Record Review and Medical Record Review General follow-up • Clarify any concerns with relevant clinical staff. • DO NOT divulge any information about your findings to the facility staff. • Meet with the facility’s administrator and/or director of nurses before leaving to thank them for their cooperation. • If you observe any diversions of scheduled (II-IV) medications record the diversion when observed and report concerns as it relates to the resident and the medication to the facility administrator before leaving. It is the administrator’s responsibility to establish the link to the individual staff member. Additional instructions • Contact each facility prior to the observations to notify them of the date and time you will arrive and ask them whom you are to contact (we suggest a week before). The arrival time should be 30 - 60 minutes prior to the time of the pass. • Complete your observations on one facility prior to starting at the next facility to assure that your observations reflect the same time period with consistent administration procedures in place. Establish 103 • • • the sampling plan based upon the typical proportion of routine medications administered by each level of credentialed administrators. Each the four observers should observe a minimum of 125 medication administrations (opportunities for error). Each observer should be clear as to what level of credential they are to watch and how they will achieve the appropriate proportion for the total facility observation. Observations must be representative of both AM and PM shifts. If two observers are assigned then each observer would observe at least 250 medication administrations at each facility. (If one observer, then at least 500.) Discuss with nursing home leadership when the majority of routine medications are given and sample accordingly (major medication administration times are typically 0800, 1200, 1600, and 2000). Schedule the observations during their primary medication administration times. If necessary you may observe more than one administration time during a shift (particularly when administrators work 12 hour shifts, as long as you observe a different administrator doing the medication administration) to ensure at least 500 medications are observed in each facility. When the administrator completes her/his entire pass, have that administrator complete the Subject Demographic Information Form. Submit the originals weekly of all forms and worksheets to Headmaster LLP by FedEx. To ensure forms/worksheets are received by Headmaster LLP, keep a copy of your data only until you are notified the originals have been received. Your copies must then be destroyed (burned or shredded). 104 Appendix Two Report of the Data: Descriptives Pre PSMT Data 95% Confidence Interval for Mean N Mean Std. Deviation Std. Error Lower Bound Total Error Rate Wrong Drug Wrong Dose Wrong Route Wrong Time Upper Bound Mini mum Maximum LPN 31 .1012 .1120 2.012E-02 6.014E-02 .1423 .00 .57 RN 7 .1154 9.476E-02 3.582E-02 2.773E-02 .2030 .00 .26 Total 38 .1038 .1080 1.752E-02 6.834E-02 .1393 .00 .57 LPN 31 2.110E-02 2.737E-02 4.915E-03 1.107E-02 3.114E-02 .00 .10 RN 7 9.557E-03 1.285E-02 4.857E-03 -2.3276E-03 2.144E-02 .00 .03 Total 38 1.898E-02 2.558E-02 4.150E-03 1.057E-02 2.739E-02 .00 .10 LPN 31 4.554E-02 5.407E-02 9.711E-03 2.571E-02 6.537E-02 .00 .20 RN 7 7.460E-02 6.496E-02 2.455E-02 1.453E-02 .1347 .00 .17 Total 38 5.089E-02 5.643E-02 9.155E-03 3.235E-02 6.944E-02 .00 .20 LPN 31 5.258E-04 2.057E-03 3.694E-04 -2.2865E-04 1.280E-03 .00 .01 RN 7 .0000 .0000 .0000 .0000 .0000 .00 .00 Total 38 4.289E-04 1.864E-03 3.023E-04 -1.8360E-04 1.041E-03 .00 .01 LPN 31 3.285E-02 6.751E-02 1.213E-02 8.087E-03 5.762E-02 .00 .30 RN 7 3.123E-02 6.729E-02 2.543E-02 -3.1003E-02 9.346E-02 .00 .18 38 3.255E-02 6.656E-02 1.080E-02 1.067E-02 5.443E-02 .00 .30 Total 105 Test of Homogeneity of Variances Levene Statistic df1 df2 Sig. .001 1 36 .973 Wrong Drug 4.498 1 36 .041 Wrong Dose .473 1 36 .496 Wrong Route 2.053 1 36 .161 Wrong Time .031 1 36 .861 Total Error Rate Statistical inferences regarding Wrong Drug in the pre PSMT data can not be made due to the Wrong Drug Sig statistic falling below a .05 level of significance in the test of homogeneity of variances. 106 ANOVA The One-Way ANOVA compares the mean of one or more groups based on one independent variable. A one-way analysis of variance (ANOVA) was conducted on the subjects’ pre PSMT error rates. The results in the following table display p values (Sig) for each error type higher than 0.05. ANOVA Sum of Squares df Mean Square 1.144E-03 1 1.144E-03 .430 36 1.195E-02 .431 37 Between Groups 7.613E-04 1 7.613E-04 Within Groups 2.346E-02 36 6.516E-04 Total 2.422E-02 37 Between Groups 4.822E-03 1 4.822E-03 Within Groups .113 36 3.139E-03 Total .118 37 Between Groups 1.579E-06 1 1.579E-06 Within Groups 1.269E-04 36 3.526E-06 Total 1.285E-04 37 Between Groups 1.504E-05 1 1.504E-05 Within Groups .164 36 4.553E-03 Total .164 37 Between Groups Total Error Rate Within Groups Total Wrong Drug Wrong Dose Wrong Route Wrong Time F Sig. .096 .759 1.168 .287 1.536 .223 .448 .508 .003 .954 This research data is unable to reject the null hypothesis. In other words, there is no statistically significant difference in medication error rates by level of credential in the pre PSMT observations due to Sig greater than .05 in all instances. 107 Descriptives Post PSMT Data N Mean Std. Deviation 95% Confidence Interval for Mean Std. Error Upper Bound Minimum Maximum Lower Bound Total Error Rate Wrong Drug Wrong Dose Wrong Route Wrong Time LPN 16 7.254E-02 5.171E-02 1.293E-02 4.499E-02 .1001 .00 .21 RN 2 2.750E-02 1.768E-02 1.250E-02 -.1313 .1863 .02 .04 PSMT 7 6.057E-02 5.072E-02 1.917E-02 1.367E-02 .1075 .01 .15 Total 25 6.559E-02 4.988E-02 9.975E-03 4.500E-02 8.618E-02 .00 .21 LPN 16 2.056E-02 2.362E-02 5.905E-03 7.971E-03 3.314E-02 .00 .08 RN 2 3.750E-03 5.303E-03 3.750E-03 -4.3898E-02 5.140E-02 .00 .01 PSMT 7 1.196E-02 1.098E-02 4.151E-03 1.800E-03 2.211E-02 .00 .03 Total 25 1.680E-02 2.026E-02 4.052E-03 8.442E-03 2.517E-02 .00 .08 LPN 16 3.031E-02 3.221E-02 8.052E-03 1.315E-02 4.747E-02 .00 .12 RN 2 3.750E-03 5.303E-03 3.750E-03 -4.3898E-02 5.140E-02 .00 .01 PSMT 7 3.257E-02 4.091E-02 1.546E-02 -5.2629E-03 7.041E-02 .00 .09 Total 25 2.882E-02 3.355E-02 6.711E-03 1.497E-02 4.267E-02 .00 .12 LPN 16 6.250E-03 2.500E-02 6.250E-03 -7.0716E-03 1.957E-02 .00 .10 RN 2 .0000 .0000 .0000 .0000 .0000 .00 .00 PSMT 7 .0000 .0000 .0000 .0000 .0000 .00 .00 Total 25 4.000E-03 2.000E-02 4.000E-03 -4.2556E-03 1.226E-02 .00 .10 LPN 16 1.543E-02 2.158E-02 5.395E-03 3.926E-03 2.692E-02 .00 .06 RN 2 2.000E-02 2.828E-02 2.000E-02 -.2341 .2741 .00 .04 PSMT 7 1.607E-02 2.495E-02 9.432E-03 -7.0072E-03 3.915E-02 .00 .06 Total 25 1.597E-02 2.195E-02 4.389E-03 6.913E-03 2.503E-02 .00 .06 108 Test of Homogeneity of Variances Levene Statistic df1 df2 Sig. .672 2 22 .521 Wrong Drug 2.620 2 22 .095 Wrong Dose 1.997 2 22 .160 Wrong Route 1.212 2 22 .317 Wrong Time .192 2 22 .826 Total Error Rate Test of Homogeneity of Variances shows if the groups have approximately equal variance on the dependent variable. If the Levene's Test is significant (the value under "Sig." is less than .05), the two variances are significantly different. If it is not significant (Sig. is greater than .05), the two variances are not significantly different; that is, the two variances are approximately equal. If the Levene's test is not significant, we can assume that the variances are approximately equal. The non-significant result in the above data is good because it shows that the homogeneity of variance assumption was not violated. Any "Sig." value below .05 would be a cause for concern. 109 ANOVA The One-Way ANOVA compares the mean of one or more groups based on one independent variable. A one-way analysis of variance (ANOVA) was conducted on the subjects’ post PSMT error rates. The results in the following table display p values (Sig) for each error type was higher than 0.05. ANOVA Total Error Rate Wrong Drug Wrong Dose Wrong Route Wrong Time Sum of Squares df Mean Square Between Groups 3.852E-03 2 1.926E-03 Within Groups 5.585E-02 22 2.539E-03 Total 5.970E-02 24 Between Groups 7.305E-04 2 3.653E-04 Within Groups 9.119E-03 22 4.145E-04 Total 9.850E-03 24 Between Groups 1.391E-03 2 6.956E-04 Within Groups 2.563E-02 22 1.165E-03 Total 2.702E-02 24 Between Groups 2.250E-04 2 1.125E-04 Within Groups 9.375E-03 22 4.261E-04 Total 9.600E-03 24 Between Groups 3.731E-05 2 1.865E-05 Within Groups 1.152E-02 22 5.237E-04 Total 1.156E-02 24 F Sig. .759 .480 .881 .428 .597 .559 .264 .770 .036 .965 The research data is unable to reject the null hypothesis. In other words, there is no statistically significant difference in medication error rates by level of credential in the post PSMT observations due to Sig greater than .05 in all instances. 110 Post Hoc Tests The results of the Post-Hoc Comparisons show exactly which pairs of groups may be significantly different. Multiple Comparisons Bonferroni 95% Confidence Interval Dependent Variable (I) DISCIPLI LPN Total Error Rate RN PSMT LPN Wrong Drug RN PSMT LPN Wrong Dose RN PSMT LPN Wrong Route RN (J) DISCIPLI Wrong Time LPN Std. Error Sig. Lower Bound Upper Bound RN 4.504E-02 3.779E-02 .738 -5.2875E-02 .1430 PSMT 1.197E-02 2.283E-02 1.000 -4.7192E-02 7.114E-02 LPN -4.5044E-02 3.779E-02 .738 -.1430 5.287E-02 PSMT -3.3071E-02 4.040E-02 1.000 -.1378 7.161E-02 LPN -1.1972E-02 2.283E-02 1.000 -7.1136E-02 4.719E-02 RN 3.307E-02 4.040E-02 1.000 -7.1608E-02 .1378 RN 1.681E-02 1.527E-02 .849 -2.2761E-02 5.637E-02 PSMT 8.599E-03 9.226E-03 1.000 -1.5308E-02 3.251E-02 LPN -1.6806E-02 1.527E-02 .849 -5.6374E-02 2.276E-02 PSMT -8.2071E-03 1.632E-02 1.000 -5.0506E-02 3.409E-02 LPN -8.5991E-03 9.226E-03 1.000 -3.2506E-02 1.531E-02 RN 8.207E-03 1.632E-02 1.000 -3.4092E-02 5.051E-02 RN 2.656E-02 2.560E-02 .932 -3.9769E-02 9.289E-02 PSMT -2.2589E-03 1.547E-02 1.000 -4.2338E-02 3.782E-02 LPN -2.6563E-02 2.560E-02 .932 -9.2894E-02 3.977E-02 PSMT -2.8821E-02 2.737E-02 .911 -9.9733E-02 4.209E-02 LPN 2.259E-03 1.547E-02 1.000 -3.7820E-02 4.234E-02 RN 2.882E-02 2.737E-02 .911 -4.2090E-02 9.973E-02 RN 6.250E-03 1.548E-02 1.000 -3.3868E-02 4.637E-02 PSMT 6.250E-03 9.355E-03 1.000 -1.7990E-02 3.049E-02 -6.2500E-03 1.548E-02 1.000 -4.6368E-02 3.387E-02 .0000 1.655E-02 1.000 -4.2888E-02 4.289E-02 -6.2500E-03 9.355E-03 1.000 -3.0490E-02 1.799E-02 RN .0000 1.655E-02 1.000 -4.2888E-02 4.289E-02 RN -4.5750E-03 1.716E-02 1.000 -4.9050E-02 3.990E-02 LPN PSMT PSMT Mean Difference (IJ) LPN 111 -6.4643E-04 1.037E-02 1.000 -2.7519E-02 2.623E-02 LPN 4.575E-03 1.716E-02 1.000 -3.9900E-02 4.905E-02 PSMT 3.929E-03 1.835E-02 1.000 -4.3617E-02 5.147E-02 LPN 6.464E-04 1.037E-02 1.000 -2.6226E-02 2.752E-02 -3.9286E-03 1.835E-02 1.000 -5.1474E-02 4.362E-02 PSMT RN PSMT RN Notice that Sig. is greater than .05 in all instances of comparison, therefore no combination of two variances are significantly different for any of the four errors tracked. 112