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Medication Aides: Regulations, Safety, & Practice

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Presentation on theme: "Medication Aides: Regulations, Safety, & Practice"— Presentation transcript:

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

2 Introduction Part I: Part II:
Medication Aide safety and practice: A review of the literature Part II: State-by-state review of Medication Aide regulations Research suggests that Medication Aides (i.e., Unlicensed Assistive Personnel that administer medications) are capable of safely administering medications. Despite this evidence, questions remain about the general safety and practice of medication aides. One potential explanation for the lingering concerns over Medication Aide safety may be the wide variations in regulations and practice both between and within states. A review of the academic literature on Medication Aide safety and practice is presented, along with an exploration of Medication Aide roles and regulations between and within states

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

4 The Medication Aide Role
May drastically vary both between and within states: job descriptions training testing supervision Job analysis (NCSBN, 2007) Concerns and uncertainty surround the role (Quallich, 2005) Future research: standard job description core competencies The Medication Aide role is not as clear cut as other patient care positions. Job descriptions, training, testing, and supervision may drastically vary both between and within states. The Medication Aide job analysis (NCSBN, 2007) provided a much needed glimpse into the overall, general, Medication Aide role and helped lay the groundwork for Medication Aide-related tests, assessment, studies, training, and development. Quallich (2005) highlighted some concerns and uncertainty of the Medical Assistant roles (which includes the Medication Aide role); for example, education concerns, questionable cost savings, temptations to inappropriately delegate, and licensed nurse job dissatisfaction. Quallich (2005) suggests that the industry must ensure that Medical Assistants are well-trained and adequately supervised and partnered with licensed nurses. Future research on the Medication Aide role could identify standard aspects of the Medication Aide role – this could include a standard job description and core competencies.

5 Medication Aide Program Implementation
Unique set of challenges: (Randolph, 2008) personnel shortages curriculum rigors licensed nurses’ initial resistance Potential benefits: (Randolph, 2008) freeing nurse time staff satisfaction increased ability to meet residents’ care needs NCSBN’s Medication Assistant model curriculum (Spector & Doherty, 2007; NCSBN, 2007) Future research: indepth investigations on program aspects Ex: amount/type of training, testing, and supervision The implementation of a Medication Aide programs may have a unique set of challenges. Randolph (2008) highlighted the following challenges: personnel shortages, curriculum rigors, and licensed nurses’ initial resistance. However, the program implementation also saw the following benefits: freeing nursing staff for other essential functions, satisfaction of all staff, and an increased ability to meet residents’ care needs. Specific Medication Aide program implementation suggestions came from Spector and Doherty (2007) and NCSBN (2007) who discussed and developed a Medication Assistant model curriculum. The authors suggested that there should be more uniformity/consistency across jurisdictions as to the training and utilization of Medication Assistants. Future research on Medication Aide program implementation that more fully investigates various aspects of programs (e.g., amount of training, testing, and supervision) is needed. For instance, does one type/amount of training, testing, and supervision result in safer Medication Aide practice over other models?

6 Medication Aide Medication Management Policies
No evidence of harm to patients receiving nurse delegation in Washington State (Young et al., 1998; Young & Sikma, 1999) Nurse delegation enhanced the quality and intensity of supervision in Washington State (Young et al., 1998; Young & Sikma, 1999) Case study of policy application (Sikma & Young, 2003) Lack of clarity in practice parameters may result in confusion and procedures that “push the envelope” (Reinhard, et al., 2003; 2006) however, no evidence of harm related to med admin Future research the effects of specific state or facility policies on outcomes Five studies that further, and in more detail, presented/examined/discussed/and informed Medication Aide medication management policies were summarized. Young, Sikma, Eyres, Ward, Strong, Bond, Shull and Mathison (1998) and Young and Sikma (1999) conducted studies to inform decision and policy making regarding nurse delegation in Washington State. There was no evidence of significant harm or adverse outcomes to patients among those receiving nurse delegation (including the delegation of medication administration to UAPs). Nurse delegation had actually enhanced the quality and intensity of supervision – it was evident that there was widespread unlicensed and unregulated medication administration without supervision prior to nurse delegation. In a related study, Sikma and Young (2003) presented a case study of policy application involving changes for nurses delegating to and supervising UAPs. And finally, Reinhard, Young, Kane, and Quinn (2003; 2006) identified state policies that affect nursing delegation of medication administration in assisted living settings in an effort to inform future multi-state studies of medication safety and quality of care in long-term care settings and to possibly help shape health policy. Study results suggest that a lack of clarity in practice parameters may result in confusion and procedures that might “push the envelope.” And professionals may be concerned about the safety of nurse delegation of medication administration; however, there was no evidence of harm related to medication administration. Future research on Medication Aide medication management policies is needed that examines the effects of specific state and facility policies of nurse delegation of medication administration on the safety of Medication Aides. For instance, what effects do facility policies regarding medication administration and quality improvement systems (e.g., technology – electronic medication records) have on Medication Aide safety?

7 Characteristics of Facilities Using Medication Aides
Only 1 study (Hughes, Wright, & Lapane, 2006) Homes that utilized Medication Technicians: “substitution” style of working fewer CNAs and RN/LPNs per 100 beds more deficiency citations related to med errors questionable supervision Future research more rigorous comparisons of facilities that do versus do not utilize Medication Aides One study (Hughes, Wright, & Lapane, 2006) examined characteristics of facilities using Medication Aides as part of their staffing structure. The researchers argued that homes that utilized Medication Technicians were often using staffing configurations that were indicative of a “substitution” style of working (i.e., using contract pharmacists or physician extenders). And homes that used Medication Technicians had fewer CNAs and RN/LPNs per 100 beds than homes that did not use Medication Technicians. The researchers also found that facilities that employed Medication Technicians had more deficiency citations for activities relating to medication errors and pharmaceutical services and posited that this may have been a function of the level of Medication Technician supervision. The authors stated that in many states, supervision of Medication Technicians by professional staff is assumed, yet the likelihood that such supervision occurs is questionable. The authors, despite study design limitations, suggested that the use of Medication Technicians to administer medications may not be advisable. Future research is needed that more rigorously compares and contrasts facilities that do and do not utilize Medication Aides. Hughes, Wright, and Lapane (2006) used a retrospective design utilizing self-reported data in only two states. Prospective studies on, for example, staffing ratios and errors are needed. A more critical analysis of facilities that do versus do not use Medication Aides could provide needed insight into the Medication Aide role (e.g., if Medication Aides are cheaper and “safe” why are not all facilities using them?).

8 Medication Aide Medication Administration Processes
Vary widely from facility-to-facility and from state-to-state. Subtle differences between “assisting” versus “administering” (Mitty, 2009) Outline of the top areas in which Med Aides need additional training (Center for Excellence in Assisted Living, 2008) Difficult to provide timely med admin to large groups of residents & communication related to administration and monitoring was the core of many problems (Vogelsmeier et al., 2007) Future research In-depth investigation of communication related to medication administration and monitoring Medication Aide medication administration processes have the potential to vary widely from facility to facility and from state to state. First, Mitty (2009) brought attention to subtle difference between the definitions of assisting versus administering medications. In the responding facilities in states where assisted living regulations do not permit UAPs to administer medications, UAPs can assist with medications in more than 90% of those facilities. Mitty (2009) went on to suggest that Boards of Nursing in every state should be authorized to develop core competencies for Medication Technicians/Aides, and that this is an opportunity for collaboration of the AALNA and NCSBN to develop best practices that could assure assisted living residents, families, and owner/operators of UAPs legitimate qualifications. Second, The Center for Excellence in Assisted Living (2008) outlined the top areas in which Medication Aides need additional training. And emphasis was placed on designing systems to proactively intervene among staff, providers, and residents to reduce errors or problems with medication management. Third, Vogelsmeier, Scott-Cawiezell, and Zellmer (2007) conducted a study to explore staff perceptions and concerns about the medication use process in the nursing home setting. Results pointed out how difficult it was to provide timely administration of medications to large groups of residents, and Medication Administrators shared stories about how they felt “set up” to administer inaccurate doses because of the existing medication use process. Also, communication related to administration and monitoring was at the core of many problems. The authors suggested technology as one avenue to improve the nursing home medication use process. In a related study, Scott-Cawiezell, Madsen, Pepper, Vogelsmeier, Petroski, and Zellmer (2009) summarized how 5 nursing homes integrated the implementation of technology and process improvement to affect medication safety practices. And finally, Morse, Colatarci, Nehring, Roth, and Barks (1997) wrote a commentary with the goal to clarify the nature and process involved in the use of UAPs to administer medication to persons with mental retardation or developmental disabilities. The authors supported the role of professional RNs in the initial and ongoing training and evaluation of UAPs. Future research is needed that more fully examines medication administration processes; for instance, a more in-depth investigation of communication related to medication administration and monitoring.

9 Delegation to Medication Aides
Assessment, evaluation, and judgment cannot be delegated – yet medication administration by UAPs often requires assessment and judgment (Mitty & flores, 2007) Administration errors were detected in 20% of doses and almost all errors (99%) occurred during preparation or recording rather than final administration (Dickens, Stubbs, & haw, 2008) Future research Nurse delegation of medication management activities and resident outcomes (Munroe, 2003) Kind and quality of education, training, and monitoring for the safety of UAP practice and on errors and adverse outcomes (Mitty & Flores, 2007) Delegation to Medication Aides was an issue in some of the earlier discussed research; however, some of the literature took more of a direct focus on medication administration processes with a focus on delegation. In general, future research is needed on nursing delegation of medication management activities and resident outcomes (Munroe, 2003) and on the kind and quality of education, training, and monitoring for the safety of UAP practice and on errors and adverse outcomes (Mitty & Flores, 2007). Mitty and Flores (2007) addressed the fact that, as stated in Nurse Practice Acts, the nursing functions of assessment, evaluation, and nursing judgment cannot be delegated – yet it is obvious that medication administration by UAPs often requires assessment and judgment. In an empirical investigation of delegation to UAPs, Dickens, Stubbs, and Haw (2008) found that administration errors were detected in 20% of doses and almost all errors (99%) could be described as occurring during preparation or recording rather than final administration (i.e., most errors were not caused by UAPs). The authors concluded that the delegation of medication administration to care workers is defensible in psychiatric settings for older people.

10 Medication Aide and Licensed Nurse Job Satisfaction and Stress
Medication Nursing Assistant role enhances nursing care and decrease stress among nurses in long-term care facilities (Walker, 2008) Future research A study with a large sample with a quantitative survey design The previous sections on medication administration addressed the fact that licensed nurses and Medication Aides may partner through delegation, the nature of this partnership has the potential to greatly affect Medication Aide and licensed nurse job satisfaction and stress. A link between the Medication Nursing Assistant role and perceived nurse satisfaction and stress was evident (Walker, 2008). Walker (2008) suggested that study results supported implementation of the Medication Nursing Assistant role to enhance nursing care and decrease stress among nurses in long-term care facilities. However, it should be noted that these conclusions were mainly drawn from the small interview data sample. Future studies would benefit from a larger sample and a more quantitative/standardized survey design. In general, more studies that more rigorously investigate job satisfaction and stress in teams of licensed nurses and Medication Aides are needed.

11 Medication Aide Medication Error Rates
Arguably, the most important aspect right drug, dose, client, time, route, & documentation No significant difference in errors by level of credential (Scott-Cawiezell, et al., 2007) UAP risks appear to be minimal & generally do well with med admin given level of preparation (Young, et al., 2008) Of 99 Cefepime administrations, 80% were incorrectly administered (Hoefel & Lautert, 2006) Future research studies with sufficient group sample sizes control for the medication administration “job” Arguably, one of the most important aspects of the safety and practice of Medication Aides is Medication Aide medication error rates. Up to this point, some of the literature discussed have mentioned error rates or have pointed out that there seems to be no safety issues with having Medication Aides as part of a health care team; however, none of the discussed literature has specifically examined potential differences in error rates between Medication Aides and licensed nurses. When it comes to Medication Aide safety and practice most stakeholders are interested in one thing: Can Medication Aides safely administer medications? Five studies were presented which specifically examined Medication Aide error rates defined in relationship to some form of the 6 rights (i.e., right drug, dose, client, time, route, and documentation) using observational methods. Scott-Cawiezell, Pepper, Madsen, Petroski, Vogelsmeir, and Zellmer (2007) found no signification differences in errors by level of credential and provided initial evidence to suggest that CMT/As are safe for routine medication administration. In a similar study, The Arizona State Board of Nursing (2008) also found no significant differences by level of credential. While, Young, Gray, McCormick, Sikma, Reinhard, Johnson, Christlieb, and Allen (2008) concluded that UAP risks appear to be minimal and that UAP generally do well with medication management, given their level of training and preparation. On the other hand, Hoefel and Lautert (2006) found that of 99 observations of cefepime administrations, 80% were incorrectly administered by Nursing Assistants/Technicians. However, overall, despite low group sample sizes the studies combined suggest that there may be no differences in errors by level of credential. Future research on Medication Aide medication error rates is needed that more fully investigates medication error rates using sufficient group sample sizes, and that control for characteristics of the medication administration “job.” That is, comparing medication error rates between groups (e.g., Medication Aide vs. LPN/VN vs. RN) has a major confound – each group does not perform the same job or administer the same medications. One solution to this problem of unequivalent groups is to design a study using a simulation methodology. A simulation would allow the 3 groups to be more closely studied for their respective error rates in a controlled environment.

12 Discussion Studies not cohesive Numerous limitations
Difficult to draw broad, generalizable, conclusions given wide variations in testing, practice, and supervision between and within states In general, studies mostly supported Medication Aides’ safety of practice Regardless of an article’s direction of support for Med Aides – recommendations for safety and practice were evident throughout The studies, overall, were not very cohesive – it was difficult to link them together in a standard manner. And many of the studies had numerous limitations. Additionally, it was difficult to draw broad, generalizable, conclusions from any one of the discussed studies given study limitations and the wide variations in medication Aide training, testing, practice, and supervision both between and within states. Despite this, and a call for more research (e.g., Munroe, 2003), when the literature is summarized together a broader picture develops and conclusions and recommendations on Medication Aide safety and practice can be derived from the global results and conclusions. In general, studies mostly supported Medication Aides’ safety of practice. First, Scott-Cawiezell et al. (2007) suggests that CMT/As do not significantly differ from RNs and LPNs in medication administration errors (defined in terms of some form of the 6 rights – right drug, dose, client, time, route, and documentation – using observational methods). This study also suggests that CMT/A’s have much less interruptions and distractions when administering medications and the authors argue that the study provides initial evidence to suggest that CMT/As are safe for routine medication administration. These results are similar to the Arizona State Board of Nursing’s (2008) study which suggested that there was no reduction in the quality of care when Medication Technicians were apart of the health care team, and Young et al.’s (2008) study which suggested that UAPs generally do well with the task of medication administration in assisted living, given their level of training and preparation when the bulk of the medications administered are low risk and routine. The authors stated that, overall, the risks appeared to be minimal. Further, Walker (2008) suggests that the implementation of the Medication Nursing Assistant role enhances nursing care and decreases stress among nurses in long-term care facilities. And Dickens et al. (2008) suggests that delegation of medication administration to care workers is defensible in psychiatric settings for older people. These results echo Burruss et al.’s (1993) study results which suggested that medication administration in the acute care community hospital setting can be safely and cost-effectively handled by non-RN personnel. The authors argued that adopting such a strategy, an acute care institution can expect better utilization of existing RN resources and improved overall institutional quality. Fewer studies were unsupportive of Medication Aide’s safety of practice. Hughes et al. (2006) suggests that the use of Medication Technicians to administer medications may not be advisable. Specifically, the authors found that facilities that employed Medication Technicians had more deficiency citations for activities relating to medication errors and pharmaceutical services (including medication administration). The authors posited that this may have been a function of the level of Medication Technician supervision, which could lead to more errors. In many states, supervision of medication technicians by professional staff is assumed. Yet, the likelihood that such supervision occurs is questionable. Further, Hoefel et al. (2006) suggests that corrective practice and safety measures should be introduced for Nursing Technicians and Assistants because of the amount of errors in administering antibiotics. Specifically, of 99 cefepime administrations, 80% were incorrectly administered. Regardless of an article’s direction of support for Medication Aides, recommendations for Medication Aide’s safety and practice were evident throughout. For instance, Mitty (2009) called for electronic medication administration records and more rigorous training and supervision of Medication Aides. Additionally, the author calls for Medication Aide/Tech “certification,” offered in some states, to be made uniform and nationwide. Vogelsmeier et al. (2007) called for technology to improve nursing home medication use processes. While Mitty and Flores (2007) suggested that UAPs should be key participants in the construction of a competency and performance evaluation tool/process – pointing out that a culture of safety requires monitoring and performance evaluation systems as well as reporting and data collection. And finally, Quallich (2005) suggested that Medication Aides could be most beneficial to a health care team when adequately supervised and partnered with a licensed nurse who clearly defines expectations, offers support, and avoids temptations to inappropriately delegate. Overall, questions about, and recommendations for, Medication Aide’s safety and practice can be expected to continue. However, at this point, when examining the literature from a global perspective, the studies mostly suggest support for Medication Aides’ safety and practice. Future research should examine: Medication Aides’ core competencies; the kind and quality of training, testing, and supervision/monitoring needed on Medication Aide practice and adverse outcomes; an examination of state and facility policies of nurse delegation of medication administration on the safety of Medication Aides; a further investigation into the characteristics of facilities that do versus do not use Medication Aides; an investigation into communication related to medication administration and monitoring; more rigorous investigation of job satisfaction and stress in teams of licensed nurses and Medication Aides; nursing delegation of medication management activities and resident outcomes; and research on error rates with sufficient group sample sizes that control for characteristics of the medication administration job.

13 Part II: State-by-State Review of Medication Aide Regulations
Exploring characteristics of Medication Aide program regulations State/jurisdiction breakdowns Regulatory oversight Applicant requirements Training Testing Continuing education and supervision Exploring Medication Aide limitations to practice by jurisdiction A state-by-state review of Medication Aide regulations was conducted by reviewing and documenting information from state/jurisdiction websites and state legislation and asking key contacts to review and answer questions not answerable through websites and state legislation. The following states’ key contacts either did not respond, could not be reached, or did not provide enough detailed information: Colorado, Connecticut, Kansas, Kentucky, Massachusetts, and Oregon Results indicated that 17 states did not allow Unlicensed Assistive Personnel to administer medications, while 34 states allowed Unlicensed Assistive Personnel to administer medications; however, these states vary wildly in the implementation of the programs and in some states there are more than one type of Unlicensed Assistive Personnel that administers medications. The following section will explore and present detailed breakdowns of characteristics of Medication Aide program regulations (e.g., training hours, testing, endorsement, etc.), followed by a section that explores medication administration restrictions by state/jurisdiction. Given study methods for obtaining the data, and ever changing state legislation, all of the results should be interpreted with caution. The purpose of the presented data is to provide a much needed snapshot of Medication Aide’s regulations and practice. Future studies should use a more systematic and controlled survey methodology.

14 Exploring Regulations: state/jurisdiction breakdowns
A series of analyses were conducted that examined the percentage of states that have Unlicensed Assistive Personnel that administer medications (i.e., Medication Aides). Results indicated that 67% (n = 34) of states have some form of Medication Aide (see Table 1); however, some states have more than one type of Medication Aide with varying types of training, testing, practice limitations, and practice setting (see Table 2). As a result, the term “jurisdiction” is used in place of “state” for certain analyses to represent the 46 jurisdictions for Medication Aides identified for the purposes of this study. Importantly, this is not to say that there are, in fact, 46 different jurisdictions for Medication Aides, in reality there could be more or less – 46 is used as a proxy for the current study. ***See handout*** Breakdown of “Jurisdictions” that Allow Unlicensed Assistive Personnel to Administer Medication (Table 2 in document) and States that do not Allow Unlicensed Assistive Personnel to Administer Medications (Table 3 in document)

15 A series of analyses were conducted that examined the percentage of states that have Unlicensed Assistive Personnel that administer medications (i.e., Medication Aides). Results indicated that 67% (n = 34) of states have some form of Medication Aide (see Table 1); however, some states have more than one type of Medication Aide with varying types of training, testing, practice limitations, and practice setting (see Table 2). As a result, the term “jurisdiction” is used in place of “state” for certain analyses to represent the 46 jurisdictions for Medication Aides identified for the purposes of this study. Importantly, this is not to say that there are, in fact, 46 different jurisdictions for Medication Aides, in reality there could be more or less – 46 is used as a proxy for the current study. States (n = 51) with Medication Aides. 32 (63%) states had Unlicensed Assistive Personnel that administer medications. 2 (4%) states had a pilot program. 6 (12%) states were under consideration. 11 (22%) did not have Unlicensed Assistive personnel that administer medications.

16 Percentage of states with UAPs that administer medications using title
Titles for Unlicensed Assistive Personnel that Administer Medications Frequency Percentage of states with UAPs that administer medications using title (n = 34) “Medication Aide” 27 79% “Medication Assistant” 9 26% “Unlicensed Personnel” 5 15% “Medication Technician” 4 12% “Medication Administrative Personnel” 1 3% Note. Some states have more than 1 title for/type of Unlicensed Assistive Personnel that administer medications. Hence, the column titled “Frequency” will not sum to “34.” The titles listed represent a category of titles that were grouped under a common title phrase (see Table 2 for the full listing of titles).

17 Percentage of jurisdictions
Facilities that Utilize Unlicensed Assistive Personnel that Administer Medications Frequency Percentage of jurisdictions (n = 46) Nursing Home/Skilled Nursing Facilities 18 39% Assisted Living Facilities 17 37% Intermediate Care Facility/Mental Retardation 9 20% Long Term Care Facilities 8 17% Residential Care Facilities 7 15% Adult Care Homes/Adult Foster Care 5 11% Correctional Facilities 4 9% Facilities for the Developmentally Disabled 3 7% Mental Health Facilities Schools Group Homes 2 4% Juvenile Facilities MISSING Other types of facilities (n = 1, for each facility): A designated swing bed unit in a general hospital Board and Lodging Boarding Care Homes Chemical Dependency Treatment Programs Child Care Center Community Living Arrangements Continuum of Care Facility District-part Long Term Care Unit of a Hospital Home Health Care Hospice Intermediate Care Facility Personal Care Assistant Services Residential-based habilitation day training and habilitation services for adults In a setting in which a licensed nurse is not regularly scheduled In a setting in which a licensed nurse is regularly scheduled and a setting in which a licensed nurse is not regularly scheduled In settings in which a licensed nurse is regularly scheduled and a setting in which a licensed nurse is not regularly scheduled and in an ambulatory health care setting Providers beyond facilities for the developmentally disabled and nursing home/skilled nursing facilities are allowed to have medication aides but are not required to have formal medication aides that are specifically regulated Any setting (as long as in compliance with state law and regulations)

18 Length of Time Medication Aides have been Practicing in Nursing Homes
SD Min Max Median Years 31 15 years, 5 months 11 years, 9 months 45 years 12 years The average length of time Medication Aides have been practicing in states where Medication Aides can practice in nursing homes across jurisdictions was 15 years and 5 months (SD = 11 years & 5 months) (see Tables 6a & 6b). However, care should be taken in interpreting this number because many respondents responded to this question without taking into consideration nursing home only. Attempts were made to classify certain jurisdictions as “not applicable” when the jurisdiction clearly did not use Medication Aides in any type of nursing home or long-term care facility. Despite this error in measurement, this analysis provides an overall idea of the average amount of time Medication Aides have been practicing across jurisdictions. Note. Care should be taken in interpreting these statistics because many respondents responded to this question without taking into consideration nursing home only. Attempts were made to classify certain jurisdictions as “not applicable” when the jurisdiction clearly did not use Medication Aides in any type of nursing home or long-term care facility. Despite this error in measurement, this analysis provides an overall idea of the average amount of time Medication Aides have been practicing across jurisdictions. Not applicable (no Med Aides in nursing homes or long-term care) (7, 15%) MISSING (8, 17%)

19 Exploring Regulations: regulatory oversight
Missing = 1 (2%)

20 Of the agencies that provide regulatory oversight:
43% (n = 20) are the Board of Nursing 44% (n = 21) are some other state department (e.g., Department of Health) 8% (n = 4) are some combination of the Board of Nursing and some other state department Missing = 1 (2%)

21 Exploring Regulations: applicant requirements

22 Percentage of Jurisdictions Requiring CNA Status Prior to Training
There are a variety of applicant requirements for entry into a Medication Aide training program. One of the major requirements is to be a Certified Nursing Assistant (CNA) prior to entry – at least 50% (n = 23) jurisdictions have this requirement.

23 Percentage of jurisdictions
CNA Experience Requirements Frequency Percentage of jurisdictions (n = 46) CNA work experience requirements 15 33% Not applicable (CNA not required) 9 20% Not required to be a CNA, but have work experience requirements 6 13% Not specified MISSING 7 15% Some jurisdictions required CNAs to have a specific amount of work experience… …while other jurisdictions don’t require applicants to be a CNA, but rather, to have other forms of work experience requirements (see Table 9b). Specific CNA Work Experience Requirements: 1,000 hours of documented work experience as a CNA within the last 24 months. 6 months experience as a CNA. A minimum of 6 months of work experience as a nurse aide within the last 2 years. Successfully complete an approved nurse aide course, nurse aide training and testing program or nurse aide competency examination and have been employed in the same facility for at least 6 consecutive months prior to the start of the medication aide course. Current employment and 2 years fulltime work experience as a CNA in an ICF/MR or current employment and 1 year fulltime work experience as a GNA in a licensed nursing home. Equivalent of at least 1 year of full-time employment as a CNA. Experience working as a CNA for 6 months. Have a minimum of 2,000 hours of experience within the 2 years prior to application, working as a CNA in a long-term care facility. Have at least 2,000 hours experience in direct patient care within the last 3 years. Have worked a minimum of 40 hours within the last 90 days with the residents to whom the student will be administering medications. Have been employed as a LNA within the past 5 years for an equivalent of 2 years of full time employment. The student shall be employed as a nurse aide by a hospice agency and shall complete 2,000 hours in direct patient care within the 3 years immediately preceding the start of the At least 1 continuous year of full-time experience as a CNA in the state. At least 2,000 hours working as a CNA in a nursing facility. At least 6 months full-time experience as a nursing assistant level 1 or the equivalent in part-time experience since graduation from a basic nursing assistant training program. Listed on the CNA Register for 6 months as an approved CNA before applying to become a CMT. Not required to be a CNA, but have work experience requirements: Not Applicable (6 months health care experience working at the board approved agency within the last year). Not Applicable (In residential care facility & have 1 year direct care experience or be an STNA). Not Applicable (1 year of work experience in a health care facility) . Not Applicable (shall have successfully completed the direct care staff training required by the Department of Social Services for employment in an assisted living facility or an approved nurse aide education program). Not applicable (Have been employed in a facility for 90 days as a nonlicensed direct care staff person. Must have been completed within the 12-month period preceding the first official day of the medication aide training program. An applicant employed as a nurse aide in a Medicare-skilled nursing facility or a Medicaid nursing facility is exempt from the 90-day requirement.). Not applicable (must have satisfactorily completed a home health aide training and competency evaluation program or a competency evaluation program).

24 Exploring Regulations: training

25 Percentage of jurisdictions that followed NCSBN’s Medication Assistant Certified (MA-C) Model Curriculum There are a variety of applicant requirements for entry into a Medication Aide training program. One of the major requirements is to be a Certified Nursing Assistant (CNA) prior to entry – at least 50% (n = 23) jurisdictions have this requirement.

26 Total Hours of Training Required n M SD Min Max Median Training hours
34 73.97 40.60 4 150 72 The average total hours of training required to become a Medication Aide across jurisdictions is hours. 2 semesters of nursing education (1, 2%) 12 credit hours (1, 2%) No formal training required (a self-study guide is available via the Adult Care Licensure Section) (1, 2%) Amount not specified (2, 4%) MISSING (7, 15%)

27 Hours of Didactic Training Required n M SD Min Max Median
Training hours 30 55.97 36.47 4.00 150.00 54.00 Hours of Clinical Training Required n M SD Min Max Median Training hours 30 22.20 14.86 0.00 40.00 20.50 The average number of didactic training hours across jurisdictions was hours, where 4 hours was the minimum and 150 hours was the maximum. The average number of clinical training hours across jurisdictions was hours, where 0 hours was the minimum and 40 hours was the maximum. Didactic: 2 semesters of nursing education (includes 8 hours of lab) (1, 2%) 10 Credit hours (1, 2%) Determined by the education program (1, 2%) Not applicable (no training required) (1, 2%) Amount not specified (5, 11%) MISSING (7, 15%) Clinical: 2 credit hours (1, 2%) Perform medication administration with patients - hours not specified (1, 2%)

28 Percentage of jurisdictions
Time Frame Training Must be Completed (not all data reported) Frequency Percentage of jurisdictions (n = 46) Not specified 11 24% Determined by training program 4 9% From 3 to 15 weeks 2 4% The clinical portion must be completed within 6 months of the theory portion. 1 day a week for 6 to 10 weeks 1 2% 1 to 2 weeks 14 days for theory, 30 days for clinical, for a total of 44 days The training hours take place over a wide variation in time frames; for example, “3 days per week, 5 hours per day” to “completed in no fewer than 20 business days and no greater than 90 days”.

29 Percentage of Jurisdictions with Some Form of Training Exception
Results also indicate that at least 41% (n = 19) jurisdictions have some form of training exception, while at least 28% (n = 13) do not…

30 Percentage of jurisdictions
Percentage of Jurisdictions with Training Exception if Education from Another State is Substantially Similar Frequency Percentage of jurisdictions (n = 46) No 10 22% Yes 9 20% Not specified 1 2% Not applicable (no training required or no training exception) 14 30% MISSING 12 26% Of the jurisdictions that have some form of training exception: (a) at least 20% (n = 9) have a training exception if the Medication Aide education from another state is substantially similar…

31 Percentage of jurisdictions
Percentage of Jurisdictions with Training Exception if Pass Exam Frequency Percentage of jurisdictions (n = 46) No 5 11% Yes 14 30% Not specified 1 2% Not applicable (no training required or no training exception) MISSING 12 26% At least 30% (n = 14) have a training exception if Medication Aides from another state pass the jurisdiction’s exam…

32 Percentage of jurisdictions
Percentage of Jurisdictions with Training Exception if Applicant has Some form of Work Experience Frequency Percentage of jurisdictions (n = 46) No 18 39% Yes 1 2% Not specified Not applicable (no training required or no training exception) 14 30% MISSING 12 26% At least 2% (n = 1) have a training exception if the applicant has some form of work experience…

33 Percentage of jurisdictions
Percentage of Jurisdictions with Training Exception if Applicant has Some form of Nursing Education Frequency Percentage of jurisdictions (n = 46) No 9 20% Yes 10 22% Not specified 1 2% Not applicable (no training required or no training exception) 14 30% MISSING 12 26% at least 22% (n = 10) of jurisdictions have a training exception if the applicant has some form of nursing education.

34 Percentage of jurisdictions
Percentage of Jurisdictions that have Training Locations in Facilities Frequency Percentage of jurisdictions (n = 46) Yes 18 39% No 14 30% Not defined 1 2% Not enough information given 2 4% Unknown Not applicable (no training required) MISSING 9 20% that at least 39% (n = 18) jurisdictions have Medication Aide training in facilities (e.g., long-term care facilities)…

35 Percentage of jurisdictions
Percentage of Jurisdictions that have Training Locations in Education Institutions Frequency Percentage of jurisdictions (n = 46) Yes – training in education institutions 28 61% No – no training in education institutions 5 11% Not defined 1 2% Not enough information given Unknown Not applicable (no training required) MISSING 9 20% and this table shows that at least 61% (n = 28) jurisdictions have Medication Aide training in some form of an educational institution (e.g., community colleges).

36 Exploring Regulations: testing

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

38 Percentage of jurisdictions
Test Administered After Training has Been Completed Frequency Percentage of jurisdictions (n = 46) Yes (written) 23 50% Yes (written & manual) 12 26% No 2 4% No – tests are a part of training Yes (written or oral & manual) 1 2% Determined by education program MISSING 5 11% At least 78% (n = 36) of jurisdictions have some form of written exam after Medication Aide training has been completed. At least 26% (n = 12) have some form of a manual exam after Medication Aide training has been completed…

39 Percentage of jurisdictions
Pass Rates for the Written Exam n M SD Min Max Median Pass rates (written) 11 .73 .17 .40 .94 .80 Pass Rates for the Written Exam Frequency Percentage of jurisdictions (n = 46) Not public information 1 2% Not tracked 8 17% Unknown 5 11% Not applicable (no written exam) 4 9% MISSING 17 37% An average of 73% (SD = 17%) of applicants across jurisdictions pass the written exam, where 40% was minimum and 94% was the maximum…

40 Percentage of jurisdictions
Passing Score for the Written Exam n M SD Min Max Median Passing score (written) 32 .77 .07 .70 .90 .80 Passing Score for the Written Exam Frequency Percentage of jurisdictions (n = 46) Determined by education program 1 2% Not Applicable (no written exam) 4 9% MISSING 9 20% while the average score needed to pass the written exam across jurisdictions was 77% (see Table 24a).

41 Percentage of jurisdictions
Passing Score for the Manual Exam Frequency Percentage of jurisdictions (n = 46) 100% 5 11% 80% with no critical items missed 1 2% Determined by education program Not applicable (no manual exam) 23 50% MISSING 16 35%

42 Percentage of jurisdictions
Number of Times Individuals are Allowed to Take Exam n M SD Min Max Median Times allowed to take exam 28 2.36 .56 1.00 3.00 2.00 Number of Times Individuals are Allowed to Take Exam Frequency Percentage of jurisdictions (n = 46) 1 time 1 2% 2 times 16 35% 3 times 11 24% No limit 3 7% Determined by education program Not applicable (no exam) 4 9% MISSING 10 22% At least 35% (n = 16) jurisdictions allow individuals to take the exam 2 times, and at least 24% (n = 11) jurisdictions allow individuals to take the exam 3 times…

43 Percentage of jurisdictions
Time Frame Individuals are Allowed to Take and Retake Exam (subset of data) Frequency Percentage of jurisdictions (n = 46) Within 30 days 1 2% Within 60 days of training completion 2nd exam completed within 45 days from failure notification 3 7% Retake within 90 days Within 3 months of training completion Within 6 months of training completion 4 9% Within 1 year of classroom training completion Within 1 year of training completion Within 1 year from the date of application Within 12 months after the first day of training a breakdown of the time frames individuals are allowed to take and retake the exam…

44 Percentage of jurisdictions
Are Individuals Allowed to Retake Training then Retake the Exam? Frequency Percentage of jurisdictions (n = 46) Yes 18 39% Candidates who fail will be withdrawn from the program 1 2% Determined by education program Not applicable (no exam) 4 9% MISSING 22 48% At least 39% (n = 18) of the jurisdictions allow individuals to retake training then retake the exam if the individuals have exhausted their first allotment of retakes.

45 Exploring Regulations: supervision and continuing education

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

47 Percentage of jurisdictions
Continuing Education Requirements and Time Frames (subset of data) Frequency Percentage of jurisdictions (n = 46) None 9 20% 8 hours, every 2 years 3 7% 7 clock hours, every 1 year 6 hours, every 1 year 2 4% 10 hours, every 2 years Competency assessment, every 2 years Clinical update, every 2 years 16 clock hours, every 2 years 1 2% 12 hours, every 1 year 8 of 24 hours medication related, every 2 years Retraining, every 2 years

48 Exploring Medication Aide Limitations to Practice by Jurisdiction
Many differences… will present 3 example jurisdictions and their practice limitations Beyond differences in the Medication Aide roles and regulations in terms of: state/jurisdiction breakdowns, regulatory oversight, applicant requirements, training, testing, continuing education and supervision, and limitations to practice, there are differences in Medication Aide practice limitations by jurisdiction. A breakdown of the practice limitation by jurisdiction follows. Note selection bias… presenting jurisdictions with shorter limitations to practice because of space and time constraints.

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

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

51 Jurisdiction 3 Do not: Convert drug dosages
Administer injectable medications (including medications via subcutaneous, intradermal, intramuscular, or itnravenous routes) Administer medications via tubes inserted into any body cavity Administer antineoplastic drugs Accept verbal/phone orders from those with prescriptive authority Dispense medications for residents temporarily out of the facility

52 Discussion Variations in training, testing, and practice, intuitively suggest that some Medication Aide program models result in better safety outcomes versus others. Should be a push for more uniformity in training, testing, and practice. A more consistent Medication Aide model may result in more assurance in the general safety and practice of Medication Aides. The current study presented a review of the academic literature on Medication Aide safety and practice, along with an exploration of Medication Aide roles and regulations between and within states. The literature was discussed in accordance with the following categories: the Medication Aide role, Medication Aide program implementation, Medication Aide medication management policies, characteristics of facilities using Medication Aides, Medication Aide medication administration processes, delegation to Medication Aides, Medication Aide and licensed nurse job satisfaction and stress, and Medication Aide medication error rates. The Medication Aide roles and regulations were discussed in terms of: state/jurisdiction breakdowns, regulatory oversight, applicant requirements, training, testing, continuing education, supervision, and practice limitations. The literature, from a global perspective, mostly suggests support for Medication Aides’ safety and practice. Despite this evidence, questions remain about the general safety and practice of Medication Aides. One potential explanation for the lingering concerns over Medication Aide safety may be the wide variations in regulations and practice both between and within states – as the state-by-state review of medication aide regulations suggests. All of these variations in training, testing, and practice do, intuitively, suggest that some Medication Aide program models result in better safety outcomes versus others. Ideally, these “best practices” should be identified and there should be a push for more uniformity in training, testing, and practice of Medication Aides nationwide. A more consistent Medication Aide model may result in more assurance in the general safety and practice of Medication Aides.


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